The Fearless Organization - Chools

the

fearlessorganization

the

fearlessorganization

Creating Psychological Safety in theWorkplace for Learning,Innovation, and Growth

Amy C. EdmondsonH A R V A R D B U S I N E S S S C H O O L

Copyright © 2019 by John Wiley & Sons, Inc. All rights reserved.

Published by John Wiley & Sons, Inc., Hoboken, New Jersey.Published simultaneously in Canada.

No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any formor by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except aspermitted under Section 107 or 108 of the 1976 United States Copyright Act, without either theprior written permission of the Publisher, or authorization through payment of the appropriateper-copy fee to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923,(978) 750-8400, fax (978) 646-8600, or on the Web at www.copyright.com. Requests to thePublisher for permission should be addressed to the Permissions Department, John Wiley & Sons, Inc.,111 River Street, Hoboken, NJ 07030, (201) 748-6011, fax (201) 748-6008, or online at http://www.wiley.com/go/permissions.

Limit of Liability/Disclaimer of Warranty: While the publisher and author have used their best effortsin preparing this book, they make no representations or warranties with respect to the accuracy orcompleteness of the contents of this book and specifically disclaim any implied warranties ofmerchantability or fitness for a particular purpose. No warranty may be created or extended by salesrepresentatives or written sales materials. The advice and strategies contained herein may not besuitable for your situation. You should consult with a professional where appropriate. Neither thepublisher nor author shall be liable for any loss of profit or any other commercial damages, includingbut not limited to special, incidental, consequential, or other damages.

For general information on our other products and services or for technical support, please contact ourCustomer Care Department within the United States at (800) 762-2974, outside the United States at(317) 572-3993 or fax (317) 572-4002.

Wiley publishes in a variety of print and electronic formats and by print-on-demand. Some materialincluded with standard print versions of this book may not be included in e-books or inprint-on-demand. If this book refers to media such as a CD or DVD that is not included in theversion you purchased, you may download this material at http://booksupport.wiley.com. For moreinformation about Wiley products, visit www.wiley.com.

Library of Congress Cataloging-in-Publication Data

Names: Edmondson, Amy C., author.Title: The fearless organization : creating psychological safety in the

workplace for learning, innovation, and growth / Amy C. Edmondson.Description: Hoboken, New Jersey : John Wiley & Sons, Inc., [2019] | Includes

index. |Identifiers: LCCN 2018033732 (print) | LCCN 2018036160 (ebook) | ISBN

9781119477228 (Adobe PDF) | ISBN 9781119477266 (ePub) | ISBN 9781119477242(hardcover)

Subjects: LCSH: Organizational behavior. | Organizationallearning—Psychological aspects. | Psychology, Industrial.

Classification: LCC HD58.7 (ebook) | LCC HD58.7 .E287 2019 (print) | DDC658.3/82—dc23

LC record available at https://lccn.loc.gov/2018033732

Cover Design: Wiley

Printed in the United States of America

10 9 8 7 6 5 4 3 2 1

http://www.copyright.com

http://www.wiley.com/go/permissions

http://www.wiley.com/go/permissions

http://booksupport.wiley.com

http://www.wiley.com

https://lccn.loc.gov/2018033732

To George

Whose curiosity and passion make him a great scientist andleader – and who knows all too well that fear is the enemy

of flourishing.

Brief Contents

Introduction xiii

PART I The Power of Psychological Safety 1

Chapter 1 The Underpinning 3

Chapter 2 The Paper Trail 25

PART II Psychological Safety at Work 51

Chapter 3 Avoidable Failure 53

Chapter 4 Dangerous Silence 77

Chapter 5 The Fearless Workplace 103

Chapter 6 Safe and Sound 129

PART III Creating a Fearless Organization 151

Chapter 7 Making it Happen 153

Chapter 8 What’s Next? 187

vii

viii Brief Contents

Appendix: Variations in survey measures to Illustrate Robustnessof Psychological Safety 213

Acknowledgments 217

About the Author 219

Index 221

Contents

Introduction xiiiWhat It Takes to Thrive in a Complex, Uncertain

World xiii

Discovery by Mistake xviOverview of the Book xviii

Endnotes xxi

PART I The Power of Psychological Safety 1

Chapter 1 The Underpinning 3Unconscious Calculators 4

Envisioning the Psychologically Safe Workplace 6An Accidental Discovery 8

Standing on Giants’ Shoulders 12

Why Fear Is Not an Effective Motivator 13

What Psychological Safety Is Not 15

Measuring Psychological Safety 19

Psychological Safety Is Not Enough 21Endnotes 22

ix

x Contents

Chapter 2 The Paper Trail 25Not a Perk 26

The Research 29An Epidemic of Silence 30

A Work Environment that Supports Learning 35

Why Psychological Safety Matters for Performance 39

Psychologically Safe Employees Are EngagedEmployees 41

Psychological Safety as the Extra Ingredient 43

Bringing Research to Practice 45

Endnotes 46

PART II Psychological Safety at Work 51

Chapter 3 Avoidable Failure 53Exacting Standards 54

Stretching the Stretch Goal 60

Fearing the Truth 63

Who Regulates the Regulators? 66Avoiding Avoidable Failure 68

Adopting an Agile Approach to Strategy 70

Endnotes 72

Chapter 4 Dangerous Silence 77Failing to Speak Up 78What Was Not Said 79

Excessive Confidence in Authority 83

A Culture of Silence 86

Silence in the Noisy Age of Social Media 92

Endnotes 97

Contents xi

Chapter 5 The Fearless Workplace 103Making Candor Real 104Extreme Candor 109Be a Don’t Knower 113When Failure Works 116Caring for Employees 119Learning from Psychologically Safe Work

Environments 123Endnotes 124

Chapter 6 Safe and Sound 129Use Your Words 130One for All and All for One 135Speaking Up for Worker Safety 138Transparency by Whiteboard 142Unleashing Talent 146Endnotes 147

PART III Creating a Fearless Organization 151

Chapter 7 Making it Happen 153The Leader’s Tool Kit 154

How to Set the Stage for Psychological Safety 158

How to Invite Participation So People Respond 167

How to Respond Productively to Voice – No MatterIts Quality 173

Leadership Self-Assessment 181

Endnotes 183

Chapter 8 What’s Next? 187Continuous Renewal 187

Deliberative Decision-Making 189

xii Contents

Hearing the Sounds of Silence 191

When Humor Isn’t Funny 193Psychological Safety FAQs 195

Tacking Upwind 208

Endnotes 209

Appendix: Variations in survey measures to Illustrate Robustnessof Psychological Safety 213

Acknowledgments 217

About the Author 219

Index 221

Introduction

“No passion so effectively robs the mind of all its powers of acting and reasoningas fear.”

—Edmund Burke, 1756.1

Whether you lead a global corporation, develop software, adviseclients, practice medicine, build homes, or work in one of today’sstate-of-the-art factories that require sophisticated computer skillsto manage complex production challenges, you are a knowledgeworker.2 Just as the engine of growth in the Industrial Revolutionwas standardization, with workers as laboring bodies confined toexecute “the one best way” to get almost any task done, growthtoday is driven by ideas and ingenuity. People must bring their brainsto work and collaborate with each other to solve problems andaccomplish work that’s perpetually changing. Organizations mustfind, and keep finding, new ways to create value to thrive over thelong term. And creating value starts with putting the talent you haveto its best and highest use.

What It Takes to Thrive in a Complex,Uncertain World

While it’s not news that knowledge and innovation have becomevital sources of competitive advantage in nearly every industry,

xiii

xiv Introduction

few managers stop to really think about the implications of thisnew reality – particularly when it comes to what it means for thekind of work environment that would help employees thrive andorganizations succeed. The goal of this book is to help you do justthat – and to equip you with some new ideas and practices to makeknowledge-intensive organizations work better.

For an organization to truly thrive in a world where innovationcan make the difference between success and failure, it is notenough to hire smart, motivated people. Knowledgeable, skilled,well-meaning people cannot always contribute what they know atthat critical moment on the job when it is needed. Sometimes thisis because they fail to recognize the need for their knowledge. Moreoften, it’s because they’re reluctant to stand out, be wrong, or offendthe boss. For knowledge work to flourish, the workplace must beone where people feel able to share their knowledge! This meanssharing concerns, questions, mistakes, and half-formed ideas. In mostworkplaces today, people are holding back far too often – reluctantto say or ask something that might somehow make them look bad.To complicate matters, as companies become increasingly globaland complex, more and more of the work is team-based. Today’semployees, at all levels, spend 50% more time collaborating than theydid 20 years ago.3 Hiring talented individuals is not enough. Theyhave to be able to work well together.

In my research over the past 20 years, I’ve shown that a factorI call psychological safety helps explain differences in performance inworkplaces that include hospitals, factories, schools, and governmentagencies. Moreover, psychological safety matters for groups as dis-parate as those in the C-suite of a financial institution and on the frontlines of the intensive care unit. My field-based research has primar-ily focused on groups and teams, because that’s how most work getsdone. Few products or services today are created by individuals actingalone. And few individuals simply do their work and then hand theoutput over to other people who do their work, in a linear, sequen-tial fashion. Instead, most work requires people to talk to each otherto sort out shifting interdependencies. Nearly everything we value

Introduction xv

in the modern economy is the result of decisions and actions that areinterdependent and therefore benefit from effective teamwork. As I’vewritten in prior books and articles, more and more of that teamworkis dynamic – occurring in constantly shifting configurations of peoplerather than in formal, clearly-bounded teams.4 This dynamic collab-oration is called teaming.5 Teaming is the art of communicating andcoordinating with people across boundaries of all kinds – expertise,status, and distance, to name the most important. But whether you’reteaming with new colleagues all the time or working in a stable team,effective teamwork happens best in a psychologically safe workplace.

Psychological safety is not immunity from consequences, nor isit a state of high self-regard. In psychologically safe workplaces, peo-ple know they might fail, they might receive performance feedbackthat says they’re not meeting expectations, and they might lose theirjobs due to changes in the industry environment or even to a lackof competence in their role. These attributes of the modern work-place are unlikely to disappear anytime soon. But in a psychologicallysafe workplace, people are not hindered by interpersonal fear. Theyfeel willing and able to take the inherent interpersonal risks of can-dor. They fear holding back their full participation more than theyfear sharing a potentially sensitive, threatening, or wrong idea. Thefearless organization is one in which interpersonal fear is minimizedso that team and organizational performance can be maximized ina knowledge intensive world. It is not one devoid of anxiety aboutthe future!

As you will learn in this book, psychological safety can make thedifference between a satisfied customer and an angry, damage-causingtweet that goes viral; between nailing a complex medical diagnosisthat leads to a patient’s full recovery and sending a critically ill patienthome too soon; between a near miss and a catastrophic industrialaccident; or between strong business performance and dramatic,headline-grabbing failure. More importantly, you will learn crucialpractices that help you build the psychologically safe workplacesthat allow your organization to thrive in a complex, uncertain, andincreasingly interdependent world.

xvi Introduction

Psychological safety is broadly defined as a climate in whichpeople are comfortable expressing and being themselves. Morespecifically, when people have psychological safety at work, theyfeel comfortable sharing concerns and mistakes without fear ofembarrassment or retribution. They are confident that they canspeak up and won’t be humiliated, ignored, or blamed. They knowthey can ask questions when they are unsure about something. Theytend to trust and respect their colleagues. When a work environmenthas reasonably high psychological safety, good things happen:mistakes are reported quickly so that prompt corrective action can betaken; seamless coordination across groups or departments is enabled,and potentially game-changing ideas for innovation are shared.In short, psychological safety is a crucial source of value creationin organizations operating in a complex, changing environment.

Yet a 2017 Gallup poll found that only 3 in 10 employees stronglyagree with the statement that their opinions count at work.6 Gallupcalculated that by “moving that ratio to six in 10 employees, organi-zations could realize a 27 percent reduction in turnover, a 40 percentreduction in safety incidents and a 12 percent increase in produc-tivity.”7 That’s why it’s not enough for organizations to simply hiretalent. If leaders want to unleash individual and collective talent, theymust foster a psychologically safe climate where employees feel freeto contribute ideas, share information, and report mistakes. Imaginewhat could be accomplished if the norm became one where employ-ees felt their opinions counted in the workplace. I call that a fearlessorganization.

Discovery by Mistake

My interest in psychological safety began in the mid-1990s whenI had the good fortune to join an interdisciplinary team of researchersundertaking a ground-breaking study of medication errors in hospi-tals. Providing patient care in hospitals presents a more extreme caseof the challenges faced in other industries – notably, the challenge

Introduction xvii

of ensuring teamwork in highly-technical, highly-customized, 24/7operations. I figured that learning from an extreme case would helpme develop new insights for managing people in other kinds oforganizations.

As part of the study, trained nurse investigators painstakinglygathered data about these potentially devastating human errorsover a six-month period, hoping to shed new light on their actualincidence in hospitals. Meanwhile, I observed how different hospitalunits worked, trying to understand their structures and cultures andseeking to gain insight into the conditions under which errors mighthappen in these busy, customized, occasionally chaotic operations,where coordination could be a matter of life-or-death. I alsodistributed a survey to get another view of how well the differentpatient care units worked as teams.

Along the way, I accidentally stumbled into the importance ofpsychological safety. As I will explain in Chapter 1, this launched meon a new research program that ultimately provided empirical evi-dence that validates the ideas developed and presented in this book.For now, let’s just say I didn’t set out to study psychological safety butrather to study teamwork and its relationship to mistakes. I thoughtthat how people work together was an important element of whatallows organizations to learn in a changing world. Psychological safetyshowed up unexpectedly – in what I would later describe as a blind-ing flash of the obvious – to explain some puzzling results in my data.Today, studies of psychological safety can be found in sectors rangingfrom business to healthcare to K–12 education. Over the past 20 years,a burgeoning academic literature has taken shape on the causes andconsequences of psychological safety in the workplace, some of whichis my own work but a great deal of which has been done by otherresearchers. We have learned a lot about what psychological safety is,how psychological safety works, and why psychological safety mat-ters. I’ll summarize key findings from these studies in this book.

Recently, the concept of psychological safety has taken holdamong practitioners as well. Thoughtful executives, managers,consultants, and clinicians in a variety of industries are seeking

xviii Introduction

to help their organizations make changes to create psychologicalsafety as a strategy to promote learning, innovation, and employeeengagement. Psychological safety received a significant boost inpopularity in the managerial blogosphere after Charles Duhiggpublished an article in the New York Times Magazine in February2016, reporting on a five-year study at Google that investigatedwhat made the best teams.8 The study examined several possibilities:Did it matter if teammates have similar educational backgrounds?Was gender balance important? What about socializing outside ofwork? No clear set of parameters emerged. Project Aristotle, as theinitiative was code-named, then turned to studying norms; that is,the behaviors and unwritten rules to which a group adheres oftenwithout much conscious attention. Eventually, as Duhigg wrote,the researchers “encountered the concept of psychological safetyin academic papers [and] everything suddenly fell into place.”9

They concluded, “psychological safety was far and away the mostimportant of the five dynamics we found.”10 Other behaviors werealso important, such as setting clear goals and reinforcing mutualaccountability, but unless team members felt psychologically safe,the other behaviors were insufficient. Indeed, as the study’s leadresearcher, Julia Rozovsky, wrote, “it’s the underpinning of the otherfour.”11 Reflecting her wonderfully concise conclusion, Chapter 1of this book is titled “The Underpinning.”

Overview of the Book

This book is divided into three parts. Part I: The Power of PsychologicalSafety consists of two chapters that introduce the concept of psycho-logical safety and offer a brief history of the research on this importantworkplace phenomenon. We’ll look at why psychological safety mat-ters, as well as why it’s not the norm in many organizations.

Chapter 1, “The Underpinning,” opens with a disguised truestory taking place in a hospital that shows at once the ordinarinessof an employee holding back at work – not sharing a concern or

Introduction xix

a question – as well as the profound implications this human reflexcan have for the quality of work in almost any organization. I willalso recall the story of how I stumbled into psychological safety byaccident early in my academic career.

Chapter 2, “The Paper Trail,” presents key findings from asystematic review of academic research on psychological safety.I don’t provide many details of individual studies but rather givean overview of how research on psychological safety has providedevidence supporting the central argument in this book – that notwenty-first century organization can afford to have a culture of fear.The Fearless Organization is not only a better place for employees, it’salso a place where innovation, growth, and performance take hold. Ifreaders want to skim this evidence and move quickly to Part II, theywill be rewarded by a series of case studies that clearly illuminate firstthe costs of not having psychological safety and next the rewards ofinvesting in building it.

The four chapters in Part II: Psychological Safety at Work presentreal-world case studies of workplaces in both private and public-sectororganizations to show how psychological safety (or its absence) shapesbusiness results and human safety performance.

Chapter 3, “Avoidable Failure,” digs into cases in whichworkplace fear allowed an illusion of business success, postponinginevitable discoveries of underlying problems that had gone unre-ported and unaddressed for a period of time. Here we will see iconiccompanies that appeared to be industry stars only to suffer dramaticand highly-publicized falls from grace. Chapter 4, “DangerousSilence,” highlights workplaces where employees, customers, orcommunities suffered avoidable physical or emotional harm becauseemployees, living in a culture of fear, were reluctant to speak up, askquestions, or get help.

Chapters 5 and 6 take us into organizations that have workeddiligently to create an environment where speaking up is enabledand expected. These organizational portraits allow us to see what afearless organization looks and feels like. They are strikingly differentfrom those highlighted in Chapters 3 and 4, but importantly they are

xx Introduction

also very different from each other. There is more than one way to befearless! Chapter 5 (“The Fearless Workplace”) presents companies(like Pixar) where creative work is directly and obviously criticalto business performance and where leaders understood the need tocreate psychological safety early in their tenure, as well as companieslike Barry-Wehmilller, an industrial equipment manufacturer thatunderwent a transformational journey to discover that the businessthrives when employees thrive. Chapter 6 (“Safe and Sound”)examines workplaces where psychological safety helps to ensureemployee and client safety and dignity.

Part III: Creating a Fearless Organization presents two chapters thatbuild on the stories and research presented so far to focus on thequestion of what leaders must do to create a fearless organization – anorganization where everyone can bring his or her full self to work,contribute, grow, thrive, and team up to produce remarkable results.

Chapter 7, “Making It Happen,” tackles the question of what youneed to do to build psychological safety – and how to get it back if it’slost. It contains the leader’s tool kit. I present a framework with threesimple (but not always easy) activities that leaders – at the top andthroughout an organization – can use to create a more engaged andvital workforce. We’ll see that creating psychological safety takes effortand skill, but the effort pays off when expertise or collaboration matterto the quality of the work. We will also see that the leader’s workis never done. It’s not a matter of checking the psychological safetybox and moving on. Building and reinforcing the work environmentwhere people can learn, innovate, and grow is a never-ending job,but a deeply meaningful one. Chapter 8, “What’s Next,” concludesthe book, updates a few stories, and offers answers to some of thequestions I am most frequently asked by people in companies aroundthe world.

*****

In an era when no individual can know or do everything neededto carry out the work that serves customers, it’s more important thanever for people to speak up, share information, contribute expertise,

Introduction xxi

take risks, and work with each other to create lasting value. Yet, asEdmund Burke wrote more than 250 years ago, fear limits our abil-ity for effective thought and action – even for the most talented ofemployees. Today’s leaders must be willing to take on the job of driv-ing fear out of the organization to create the conditions for learning,innovation, and growth. I hope this book will help you do just that.

Endnotes

1. Burke, E. A Philosophical Inquiry into the Origin of Our Ideas of the Sublimeand Beautiful. Dancing Unicorn Books, 2016. Print.

2. Selingo, J.J. “Wanted: Factory Workers, Degree Required.” The NewYork Times. January 30, 2017. https://www.nytimes.com/2017/01/30/education/edlife/factory-workers-college-degree-apprenticeships.html Accessed June 13, 2018.

3. Cross, R., Rebele, R., & Grant, A. “Collaborative Overload.”Harvard Business Review. January 1, 2016. https://hbr.org/2016/01/collaborative-overload Accessed June 13, 2018.

4. Edmondson, A.C. “Teamwork on the fly.” Harvard Business Review90.4, April 2012. 72–80. Print.

5. Edmondson, A.C. Teaming: How Organizations Learn, Innovate, andCompete in the Knowledge Economy. San Francisco: Jossey-Bass, 2012.Print.

6. Gallup. State of the American Workplace Report. Gallup: Washington,D.C, 2017. http://news.gallup.com/reports/199961/state-american-workplace-report-2017.aspx Accessed June 13, 2018.

7. Gallup, State of the American Workplace Report. 2012: 1128. Duhigg, C. “What Google Learned From Its Quest to Build the Per-

fect Team” The New York Times Magazine. February 25, 2016. https://www.nytimes.com/2016/02/28/magazine/what-google-learned-from-its-quest-to-build-the-perfect-team.html Accessed June 13,2018.

9. Ibid.10. Rozovsky, J. “The five keys to a successful Google team.” re:Work

Blog. November 17, 2015. https://rework.withgoogle.com/blog/five-keys-to-a-successful-google-team/ Accessed June 13, 2018.

11. Ibid.

https://www.nytimes.com/2017/01/30/education/edlife/factory-workers-college-degree-apprenticeships.html



https://hbr.org/2016/01/collaborative-overload

http://news.gallup.com/reports/199961/state-american-workplace-report-2017.aspx

http://news.gallup.com/reports/199961/state-american-workplace-report-2017.aspx

https://www.nytimes.com/2016/02/28/magazine/what-google-learned-from-its-quest-to-build-the-perfect-team.html

https://rework.withgoogle.com/blog/five-keys-to-a-successful-google-team


https://hbr.org/2016/01/





https://hbr.org/2016/01/collaborative-overload

PART

I The Power ofPsychological Safety

1The Underpinning

“Psychological safety was by far the most important of the five key dynamics wefound. It’s the underpinning of the other four.”

—Julia Rozovsky,“The five keys to a successful Google team.”1

The tiny newborn twins seemed healthy enough, but their earlyarrival at only 27 weeks’ gestation meant they were considered“high risk.” Fortunately, the medical team at the busy urban hospitalwhere the babies were delivered included staff from the NeonatalIntensive Care Unit (NICU): a young Neonatal Nurse Practitionernamed Christina Price∗ and a silver-haired neonatologist namedDr. Drake. As Christina looked at the babies, she was concerned.Her recent training had included, as newly established best practice,administering a medicine that promoted lung development as soonas possible for a high-risk baby. Babies born very prematurely oftenarrive with lungs not quite ready for fully independent breathing

∗Names in this story are pseudonyms.

3

4 The Power of Psychological Safety

outside the womb. But the neonatologist had not issued an orderfor the medicine, called a prophylactic surfactant. Christina steppedforward to remind Dr. Drake about the surfactant and then caughtherself. Last week she’d overheard him publicly berate another nursefor questioning one of his orders. She told herself that the twinswould probably be fine – after all, the doctor probably had a reasonfor avoiding the surfactant, still considered a judgment call – and shedismissed the idea of bringing it up. Besides, he’d already turned onhis heel, off for his morning rounds, white coat billowing.

Unconscious Calculators

In hesitating and then choosing not to speak up, Christina wasmaking a quick, not entirely conscious, risk calculation – the kindof micro-assessment most of us make numerous times a day. Mostlikely she was not even aware that she had weighed the risk of beingbelittled or berated against the risk that the babies might in factneed the medication to thrive. She told herself the doctor knewbetter than she did, and she was not confident he would welcomeher input. Inadvertently, she had done something psychologists calldiscounting the future – underweighting the more important issueof the patients’ health, which would take some time to play out,and overweighting the importance of the doctor’s possible response,which would happen immediately. Our spontaneous tendency todiscount the future explains the prevalence of many unhelpful orunhealthy behaviors – whether eating that extra piece of chocolatecake or procrastinating on a challenging assignment – and the failureto speak up at work is an important and often overlooked exampleof this problematic tendency.

Like most people, Christina was spontaneously managing herimage at work. As noted sociologist Erving Goffman argued inhis seminal 1957 book, The Presentation of the Self in EverydayLife, as humans, we are constantly attempting to influence others’

The Underpinning 5

perceptions of us by regulating and controlling information in socialinteractions.2 We do this both consciously and subconsciously.

Put another way, no one wakes up in the morning excited togo to work and look ignorant, incompetent, or disruptive. These arecalled interpersonal risks, and they are what nearly everyone seeks toavoid, not always consciously.3 In fact, most of us want to look smart,capable, or helpful in the eyes of others. No matter what our line ofwork, status, or gender, all of us learn how to manage interpersonalrisk relatively early in life. At some point during elementary school,children start to recognize that what others think of them matters,and they learn how to lower the risk of rejection or scorn. By thetime we’re adults, we’re usually really good at it! So good, we do itwithout conscious thought. Don’t want to look ignorant? Don’t askquestions. Don’t want to look incompetent? Don’t admit to mistakesor weaknesses. Don’t want to be called disruptive? Don’t make sug-gestions. While it might be acceptable at a social event to privilegelooking good over making a difference, at work this tendency can leadto significant problems – ranging from thwarted innovation to poorservice to, at the extreme, loss of human life. Yet avoiding behaviorsthat might lead others to think less of us is pretty much second naturein most workplaces.

As influential management thinker Nilofer Merchant said abouther early days as an administrator at Apple, “I used to go to meetingsand see the problem so clearly, when others could not.” But worryingabout being “wrong,” she “kept quiet and learned to sit on my handslest they rise up and betray me. I would rather keep my job by stayingwithin the lines than say something and risk looking stupid.”4 In onestudy investigating employee experiences with speaking up, 85% ofrespondents reported at least one occasion when they felt unable toraise a concern with their bosses, even though they believed the issuewas important.5

If you think this behavior is limited to those lower in the organi-zation, consider the chief financial officer recruited to join the seniorteam of a large electronics company. Despite grave reservations about


a planned acquisition of another company, the new executive saidnothing. His colleagues seemed uniformly enthusiastic, and he wentalong with the decision. Later, when the takeover had clearly failed,the executives gathered with a consultant for a post-mortem. Eachwas asked to reflect on what he or she might have done to contributeto or avert the failure. The CFO, now less of an outsider, shared hisearlier concerns, acknowledging that he had let the team down bynot speaking up. Openly apologetic and emotional, he lamented thatthe others’ enthusiasm had left him afraid to be “the skunk at thepicnic.”

The problem with sitting on our hands and staying within thelines rather than speaking up is that although these behaviors keepus personally safe, they can make us underperform and becomedissatisfied. They can also put the organization at risk. In the caseof Christina and the newborns, fortunately, no immediate damagewas done, but as we will see in later chapters, the fear of speakingup can lead to accidents that were in fact avoidable. Remainingsilent due to fear of interpersonal risk can make the differencebetween life and death. Airplanes have crashed, financial institutionshave fallen, and hospital patients have died unnecessarily becauseindividuals were, for reasons having to do with the climate inwhich they worked, afraid to speak up. Fortunately, it doesn’t haveto happen.

Envisioning the Psychologically Safe Workplace

Had Christina worked in a hospital unit where she felt psycholog-ically safe, she would not have hesitated to ask the neonatologistwhether or not he thought treating the newborns with prophylacticlung medicine was warranted. Here too, she might not even be awareof making a conscious decision to speak up; it would simply seemnatural to check. She would take for granted that her voice was appre-ciated, even if what she said didn’t lead to a change in the patient’s care.In a climate characterized by psychological safety – which blends trust

The Underpinning 7

and respect – the neonatologist might quickly agree with Christinaand call the pharmacy to put in a request, or he might have explainedwhy he thought it wasn’t warranted in this case. Either way, the unitwould be better off as a result. The patients would have receivedlife-saving medication, or the team would have learned more aboutthe subtleties of neonatal medicine. Before leaving the room, the doc-tor might thank Christina for her intervention. He’d be glad he couldrely on her to speak up in case he slipped up, missed a detail, or wassimply distracted.

Finally, as she gave the medicine to the babies, Christina mightcome up with the idea that the NICU could institute a protocol tomake sure that that all babies who need a surfactant would get it.She might seek out her manager to make this suggestion during abreak in the action. And because psychological safety exists in workgroups, rather than between specific individuals (such as Christinaand Dr. Drake), it’s likely her nurse manager would be receptive toher suggestion.

Speaking up describes back-and-forth exchanges people have atwork – from volunteering a concern in a meeting to giving feed-back to a colleague. It also includes electronic communication (forexample, sending an extra email to ask a coworker to clarify a partic-ular point or seek help with a project). Valuable forms of speaking upinclude raising a different point of view in a conference call, askinga colleague for feedback on a report, admitting that a project is overbudget or behind schedule, and so on – the myriad verbal interactionsthat make up the world of twenty-first century work.

There is, of course, a range of interpersonal riskiness involvedin speaking up. Some cases of speaking up occur after significanttrepidation; others feel reasonably straightforward and feasible.Still others simply don’t occur – as in the case of Christina in theNICU – because one has weighed the risk (consciously or not)and come out on the side of silence. The free exchange of ideas,concerns or questions is routinely hindered by interpersonal fear farmore often than most managers realize. This kind of fear cannot bedirectly seen. Silence – when voice was possible – rarely announces


itself! The moment passes, and no one is the wiser except the personwho held back.

I have defined psychological safety as the belief that the workenvironment is safe for interpersonal risk taking.6 The concept refersto the experience of feeling able to speak up with relevant ideas, ques-tions, or concerns. Psychological safety is present when colleaguestrust and respect each other and feel able – even obligated – to becandid.

In workplaces with psychological safety, the kinds of smalland potentially consequential moments of silence experienced byChristina are far less likely. Speaking up occurs instead, facilitatingthe open and authentic communication that shines the light onproblems, mistakes, and opportunities for improvement and increasesthe sharing of knowledge and ideas.

As you will see, our understanding of interpersonal risk manage-ment at work has advanced since Goffman studied the fascinatingmicro-dynamics of face-saving. We now know that psychologicalsafety emerges as a property of a group, and that groups in organi-zations tend to have very interpersonal climates. Even in a companywith a strong corporate culture, you will find pockets of both highand low psychological safety. Take, for instance, the hospital whereChristina works. One patient care unit might be a place where nursesreadily speak up to challenge or inquire about care decisions, while inanother it feels downright impossible. These differences in workplaceclimate shape behavior in subtle but powerful ways.

An Accidental Discovery

As much as I’m passionate about the ideas in this book, I didn’t set outto study psychological safety on purpose. As a first-year doctoral stu-dent in the process of clarifying my research interests for my eventualdissertation, I had been fortunate to join a large team studying medicalerror in several hospitals. This was a great way to gain research expe-rience and to sharpen my general interest in how organizations can

The Underpinning 9

learn and succeed in an increasingly challenging, fast-paced world.I had long been interested in the idea of learning from mistakes forachieving excellence.

My role in the research team was to examine the effects of team-work on medical error rates. The team had numerous experts, includ-ing physicians who could judge whether human error had occurredand trained nurse investigators who would review medical charts andinterview frontline caregivers in patient care units in two hospitalsto obtain error rates for each of these teams. These experts were, ineffect, getting the data for what would be the dependent variable inmy study – the team-level error rates. This was a great arrangementfor me, for at least two reasons. First, I lacked the medical expertise toidentify medical errors on my own. Second, from a research methodsperspective, it meant that my survey measures of team effectivenesswould not be subject to experimenter bias – the cognitive tendencyfor a researcher to see what she wants to see rather than what is actu-ally there. So the independence of our data collection activities wasan important strength of the study.7

The nurse investigators collected error data over a six-monthperiod. During the first month, I distributed a validated instrumentcalled the team diagnostic survey to everyone working in the studyunits – doctors, nurses, and clerks – slightly altering the languageof the survey items to make sure they would make sense to peopleworking in a hospital, and adding a few new items to assess people’sviews about making mistakes. I also spent time on the floor (in thepatient care units) observing how each of the teams worked.

Going into the study, I hypothesized, not surprisingly, that themost effective teams would make the fewest errors. Of course, I hadto wait six months for the data on the dependent variable (the errorrates) to be fully collected. And here is where the story took an unex-pected turn.

First, the good news (from a research perspective anyway).There was variance! Error rates across teams were strikingly different;indeed, there was a 10-fold difference in the number of human errorsper thousand patient days (a standard measure) from the best to the


worst unit on what I sincerely believed was an important performancemeasure. A wrong medicine dosage, for example, might be reportedevery three weeks on one ward but every other day on another.Likewise, the team survey data also showed significant variance.Some teams were much stronger – their members reported moremutual respect, more collaboration, more confidence in their abilityto deliver great results, more satisfaction, and so on – than others.

When all of the error and survey data were compiled, I was at firstthrilled. Running the statistical analysis, I immediately saw that therewas a significant correlation between the independently collectederror rates and the measures of team effectiveness from my survey. Butthen I looked closely and noticed something wrong. The directionof the correlation was exactly the opposite of what I had predicted.Better teams were apparently making more – not fewer – mistakes thanless strong teams. Worse, the correlation was statistically significant. Ibriefly wondered how I could tell my dissertation chair the bad news.This was a problem.

No, it was a puzzle.Did better teams really make more mistakes? I thought about the

need for communication between doctors and nurses to produce safe,error-free care. The need to ask for help, to double-check each other’swork to make sure, in this complex and customized work environ-ment, that patients received the best care. I knew that great care meantthat clinicians had to team up effectively. It just didn’t make sense thatgood teamwork would lead to more errors. I wondered for a momentwhether better teams got overconfident over time and then becamesloppy. That might explain my perplexing result. But why else mightbetter teams have higher error rates?

And then came the eureka moment. What if the better teams hada climate of openness that made it easier to report and discuss error?The good teams, I suddenly thought, don’t make more mistakes; theyreport more. But having this insight was a far cry from proving it.

I decided to hire a research assistant to go out and study thesepatient care teams carefully, with no preconceptions. He didn’t knowwhich units had made more mistakes, or which ones scored better on

The Underpinning 11

the team survey. He didn’t even know my new hypothesis. In researchterms, he was “blind” to both the hypothesis and the previously col-lected data.8

Here is what he found. Through quiet observation andopen-ended interviews about all aspects of the work environment,he discovered that the teams varied wildly in whether people feltable to talk about mistakes. And these differences were almostperfectly correlated with the detected error rates. In short, peoplein the better teams (as measured by my survey, but unbeknownstto the research assistant) talked openly about the risks of errors,often trying to find new ways to catch and prevent them. It wouldtake another couple of years before I labeled this climate differencepsychological safety. But the accidental finding set me off on a newand fruitful research direction: to find out how interpersonal climatemight vary across groups in other workplaces, and whether it mightmatter for learning and speaking up in other industries – not just inhealthcare.

Over the years, in studies in companies, hospitals, and even gov-ernment agencies, my doctoral students and I have found that psy-chological safety does indeed vary, and that it matters very much forpredicting both learning behavior and objective measures of perfor-mance. Today, researchers like me have conducted dozens of studiesshowing greater learning, performance, and even lower mortality as aresult of psychological safety. In Chapter 2, I will tell you about someof the studies.

In that initial study over two decades ago, I learned that psycho-logical safety varies across groups within hospitals. Since that time, Ihave replicated this finding in many industry settings. The data areconsistent in this simple but interesting finding: psychological safetyseems to “live” at the level of the group. In other words, in the organi-zation where you work, it’s likely that different groups have differentinterpersonal experiences; in some, it may be easy to speak up andbring your full self to work. In others, speaking up might be expe-rienced as a last resort – as it did in some of the patient-care teamsI studied. That’s because psychological safety is very much shaped by


local leaders. As I will elaborate later in this book, subsequent researchhas borne out my initial, accidental discovery.

Standing on Giants’ Shoulders

I might have stumbled into psychological safety by accident, butunderstanding of its importance traces back to organizational changeresearch in the early 1960s. Massachusetts Institute of Technologyprofessors Edgar Schein and Warren Bennis wrote about the needfor psychological safety to help people cope with the uncertaintyand anxiety of organizational change in a 1965 book.9 Scheinlater noted that psychological safety was vital for helping peopleovercome the defensiveness and “learning anxiety” they face at work,especially when something doesn’t go as they’d hoped or expected.10

Psychological safety, he argued, allows people to focus on achievingshared goals rather than on self-protection.

Later seminal work by Boston University professor William Kahnin 1990 showed how psychological safety fosters employee engage-ment.11 Drawing from rich case studies of a summer camp and anarchitecture firm, Kahn explored the conditions in which peopleat work can engage and express themselves rather than disengageor defend themselves. Meaningfulness and psychological safety bothmattered. But Kahn further noted that people are more likely tobelieve they’ll be given the benefit of the doubt – a wonderful wayto think about psychological safety – when they experience trust andrespect at work.

Next, my dissertation introduced and tested the idea that psy-chological safety was a group-level phenomenon.12 Building on theunexpected insights into interpersonal climate from the hospital errorstudy, I studied 51 teams in a manufacturing company in the Mid-west, measuring psychological safety on purpose this time. Publishedin 1999 in a leading academic journal, this research – which laterinfluenced Google’s celebrated Project Aristotle, discussed in Chapter2 – showed that psychological safety differed substantially across teams

The Underpinning 13

in the company and that it enabled both team learning behaviors andteam performance.13

A key insight from this work was that psychological safety is not apersonality difference but rather a feature of the workplace that lead-ers can and must help create. More specifically, in every companyor organization I’ve since studied, even some with famously strongcorporate cultures, psychological safety has been found to differ sub-stantially across groups. Nor was psychological safety the result of arandom or elusive group chemistry. What was clear was that leadersin some groups had been able to effectively create the conditions forpsychological safety while other leaders had not. This is true whetheryou’re looking across floors in a hospital, teams in a factory, branchesin a retail bank, or restaurants in a chain.

The results of my dissertation research bolstered my confidencethat all of us are subject to subtle interpersonal risks at work thatcan be mitigated. Whether explicitly or implicitly, when you’re atwork, you’re being evaluated. In a formal sense, someone higher up inthe hierarchy is probably tasked with assessing your performance. Butinformally, peers and subordinates are sizing you up all the time. Ourimage is perpetually at risk. At any moment, we might come across asignorant, incompetent, or intrusive, if we do such things as ask ques-tions, admit mistakes, offer ideas, or criticize a plan. Unwillingness totake these small, insubstantial risks can destroy value (and often does,as you will see in Chapters 3 and 4). But they can also be overcome.People at work do not need to be crippled by interpersonal fear. It ispossible to build environments, such as those showcased in Chapters5 and 6, where people are more afraid of failing the customer than oflooking bad in front of their colleagues.

Why Fear Is Not an Effective Motivator

Fear may have once acted to motivate assembly line workers on thefactory floor or farm workers in the field – jobs that reward individ-ual speed and accuracy in completing repetitive tasks. Most of us have


been exposed to, and internalized, the figure of a villainous boss whorules by fear. Indeed, popular culture has exaggerated the stereotypeto become comical, as in the animated Pixar film Ratatouille, whereRemy the rat, the story’s cartoon hero, must first overcome the tyran-nical restaurant chef who rules the kitchen if he is to realize his dreamof becoming a chef.

Worse, many managers – both consciously and not – still believein the power of fear to motivate. They assume that people who areafraid (of management or of the consequences of underperforming)will work hard to avoid unpleasant consequences, and good thingswill happen. This might make sense if the work is straightforward andthe worker is unlikely to run into any problems or have any ideas forimprovement. But for jobs where learning or collaboration is requiredfor success, fear is not an effective motivator.

Brain science has amply demonstrated that fear inhibits learningand cooperation. Early twentieth century behavioral scientist IvanPavlov, who housed dozens of dogs in his laboratory, found their abil-ity to learn behavioral tasks was inhibited after they’d been frightenedin the Leningrad flood of 1924. The lab workers who swam in torescue the animals reported that water had filled the cage, with onlythe dogs’ noses visible above water.14 Since then, neuroscientists havediscovered that fear activates the amygdala, the section of the brainthat is responsible for detecting threats. If you’ve ever felt your heartpound your palms sweat before making an important presentation,that’s due to the automatic responses of your amygdala.

Fear inhibits learning. Research in neuroscience shows that fearconsumes physiologic resources, diverting them from parts of thebrain that manage working memory and process new information.This impairs analytic thinking, creative insight, and problem solv-ing.15 This is why it’s hard for people to do their best work whenthey are afraid. As a result, how psychologically safe a person feelsstrongly shapes the propensity to engage in learning behaviors, such asinformation sharing, asking for help, or experimenting. It also affectsemployee satisfaction. Hierarchy (or, more specifically, the fear it cre-ates when not handled well) reduces psychological safety. Research

The Underpinning 15

shows that lower-status team members generally feel less safe thanhigher-status members. Research also shows that we are constantlyassessing our relative status, monitoring how we stack up against oth-ers, again mostly subconsciously. Further, those lower in the statushierarchy experience stress in the presence of those with higher sta-tus.16

Psychological safety describes a belief that neither the formal norinformal consequences of interpersonal risks, like asking for help oradmitting a failure, will be punitive. In psychologically safe environ-ments, people believe that if they make a mistake or ask for help, oth-ers will not react badly. Instead, candor is both allowed and expected.Psychological safety exists when people feel their workplace is anenvironment where they can speak up, offer ideas, and ask ques-tions without fear of being punished or embarrassed. Is this a placewhere new ideas are welcomed and built upon? Or picked apart andridiculed? Will your colleagues embarrass or punish you for offeringa different point of view? Will they think less of you for admittingyou don’t understand something?

What Psychological Safety Is Not

As more and more consultants, managers, and other observers oforganizational life are talking about psychological safety, the risk ofmisunderstanding what the concept is all about has intensified. Hereare some common misconceptions, along with clarifications.

Psychological Safety Is Not About Being Nice

Working in a psychologically safe environment does not mean thatpeople always agree with one another for the sake of being nice. Italso does not mean that people offer unequivocal praise or uncondi-tional support for everything you have to say. In fact, you could sayit’s the opposite. Psychological safety is about candor, about making


it possible for productive disagreement and free exchange of ideas.It goes without saying that these are vital to learning and innova-tion. Conflict inevitably arises in any workplace. Psychological safetyenables people on different sides of a conflict to speak candidly aboutwhat’s bothering them.

In many companies in which I’ve consulted or conductedresearch, I’ll hear a variation of the following: “We have a problemwith ‘[Company Name] Nice’.” They go on to describe thecommon experience of being “polite” to one another in meetings,only to disagree later when people talk privately in the hallway,along with a tendency to not actually implement that which wasdiscussed in the meeting. Nice, in short, is not synonymous withpsychologically safe. In a related vein, psychological safety does notimply ease or comfort. In contrast, psychological safety is aboutcandor and willingness to engage in productive conflict so as to learnfrom different points of view.

Psychological Safety Is Not a Personality Factor

Some have interpreted psychological safety as a synonym for extrover-sion. They might have previously concluded that people don’t speakup at work because they’re shy or lack confidence, or simply prefer tokeep to themselves. However, research shows that the experience ofpsychological safety at work is not correlated with introversion andextroversion.17 This is because psychological safety refers to the workclimate, and climate affects people with different personality traits inroughly similar ways. In a psychologically safe climate, people willoffer ideas and voice their concerns regardless of whether they tendtoward introversion or extroversion.

Psychological Safety Is Not Just Another Word for Trust

Although trust and psychological safety have much in common,they are not interchangeable concepts. A key difference is that

The Underpinning 17

psychological safety is experienced at a group level. People workingtogether tend to have similar perceptions of whether or not theclimate is psychologically safe. Trust, on the other hand, refers tointeractions between two individuals or parties; trust exists in themind of an individual and pertains to a specific target individual ororganization. For instance, you might trust one colleague but notanother. Or, to illustrate trust in an organization, you might trust aparticular company to uphold high standards.

Further, psychological safety describes a temporally immediateexperience. Whereas trust describes an expectation about whetheranother person or organization can be counted on to do what itpromises to do in some future moment, the psychological experienceof safety pertains to expectations about immediate interpersonal con-sequences. For example, when Christina fails to ask a physician abouta medication she believes might be warranted, she is worried aboutthe immediate consequence of asking her question – the risk of beingberated or humiliated. Trust pertains instead to whether Christinabelieves the doctor can and will do the right thing for patients. Oneway to put this is that trust is about giving others the benefit of thedoubt, and psychological safety relates to whether others will giveyou the benefit of the doubt when, for instance, you have asked forhelp or admitted a mistake.

Psychological Safety Is Not About Lowering Performance Standards

Psychological safety is not an “anything goes” environment wherepeople are not expected to adhere to high standards or meetdeadlines. It is not about becoming “comfortable” at work. This isparticularly important to understand because many managers appre-ciate the appeal of error-reporting, help-seeking, and other proactivebehavior to help their organizations learn. At the same time, theyimplicitly equate psychological safety with relaxing performancestandards – that is, with an inability to, in their words, “hold peopleaccountable.” This conveys a misunderstanding of the nature of the


Low Standards High Standards

High Psychological Safety Comfort Zone Learning & HighPerformance Zone

Low Psychological Safety Apathy Zone Anxiety Zone

Figure 1.1 How Psychological Safety Relates toPerformance Standards.18

phenomenon. Psychological safety enables candor and openness and,as such, thrives in an environment of mutual respect. It means thatpeople believe they can – and must – be forthcoming at work. Infact, psychological safety is conducive to setting ambitious goals andworking toward them together. Psychological safety sets the stagefor a more honest, more challenging, more collaborative, and thusalso more effective work environment. As Chapter 2 will explain,researchers around the world have found that psychological safetypromotes high performance in a wide range of work environmentsand industries. In short, as depicted in Figure 1.1, psychologicalsafety and performance standards are two separate, equally impor-tant dimensions – both of which affect team and organizationalperformance in a complex interdependent environment.

When both psychological safety and performance standards arelow (lower left), the workplace becomes a kind of “apathy zone.”People show up at work, but their hearts and minds are elsewhere.They choose self-protection over exertion every time. Discretionaryeffort might be spent perusing social media or on making each other’slives miserable.

Next, in workplaces with high psychological safety but low per-formance standards (upper left), people generally enjoy working withone another; they are open and collegial but not challenged by thework. Let’s call this the “comfort zone.” Today, fewer workplacesaround the world than ever fall into this quadrant, and it’s just aswell. When employees are comfortable being themselves but don’tsee a compelling reason to seek additional challenge, there won’t be

The Underpinning 19

much learning or innovation – nor will there be much engagementor fulfillment.

But it’s not the comfort or apathy zones that worry me most.What keeps me up at night is the lower right-hand quadrant. Whenperformance standards are high but psychological safety is low – a sit-uation far too common in today’s workplace – employees are anxiousabout speaking up, and both work quality and workplace safety suffer.In Chapters 3 and 4, you will see many such workplaces. Managers inthese organizations have unfortunately confused setting high standardswith good management. High standards in a context where there isuncertainty or interdependence (or both) combined with a lack ofpsychological safety comprise a recipe for suboptimal performance.And sometimes, as you will see in the chapters ahead, it’s a recipe fordisaster. I call this the “anxiety zone.” Here I’m not referring to anx-iety about being able to accomplish a demanding goal or about thecompetitive business environment but rather to interpersonal anxiety.The experience of having a question or an idea but not feeling ableto share it can be deeply unsatisfying at work. And it is a serious riskfactor in any company facing volatility, uncertainty, complexity, andambiguity, or VUCA – the acronym introduced by the U.S. ArmyWar College and widely used in the business world today.19

Finally, when standards and psychological safety are both high(upper right in Figure 1.1), I call this the learning zone. If the work isuncertain, interdependent, or both, this is also the high-performancezone. Here, people can collaborate, learn from each other, and getcomplex, innovative work done. In a VUCA world, high perfor-mance occurs when people are actively learning as they go.

Measuring Psychological Safety

Researchers and managers have useful tools at their disposal to mea-sure psychological safety, and these are in the public domain. Sur-veys are certainly the most popular of these, and Figure 1.2 presentsseven survey items, introduced in my dissertation and widely used in


1. If you make a mistake on this team, it is often held against you. (R)

2. Members of this team are able to bring up problems and tough issues.

3. People on this team sometimes reject others for being different. (R)

4. It is safe to take a risk on this team.

5. It is difficult to ask other members of this team for help. (R)

6. No one on this team would deliberately act in a way that undermines my efforts.

7. Working with members of this team, my unique skills and talents are valued and utilized.

Figure 1.2 A Survey Measure of Psychological Safety.20

the research community ever since. I use a seven-point Likert scale(from strongly agree to strongly disagree) to obtain responses, but afive-point scale works as well. Note that three of the seven itemsare expressed positively, such that agreement indicates greater psy-chological safety, and three are expressed negatively (represented inFigure 1.2 with an “R” for reverse), such that disagreement is consis-tent with higher psychological safety. In analyzing the data, therefore,it is important to “reverse score” data from the negatively wordeditems, where a 1 in the data set is converted to a 7, a 7 to a 1, a 2 toa 6, and so on.

Fortunately, the psychological safety measure has proven to berobust despite variations in both the number and the wording of theitems used. By robust, I mean that the collected data demonstrate thenecessary statistical properties, such as inter-item reliability as mea-sured by Chronbach’s alpha and predictive validity, as measured bycorrelations with other variables of interest. The appendix at the backof the book shows some of the survey item variations of which I amaware. The measure has also been translated into numerous other lan-guages, including German, Spanish, Russian, Japanese, Chinese, andKorean, all of which have yielded robust research findings.

In purely qualitative case-study research, interview data can becoded to detect the presence or absence of psychological safety.

The Underpinning 21

Several examples of research where this approach has been takenare found in Chapter 2. Another fruitful approach is to provideinterviewees with hypothetical scenarios that fall into gray areasat work and ask them what they or their colleagues might do inthat situation. When people trust that their answers will be keptconfidential, they will be quite open in reporting that they wouldhold back unless they were extremely confident that what they wantto say will be well received. Well-designed vignettes, with questionsasking about how people would respond, can also be used to collectdata from a larger number of employees than individual interviewswill allow. I will mention examples of both approaches in Chapter 2.

Psychological Safety Is Not Enough

I do not mean to imply that psychological safety is all you need forhigh performance. Not even close. I like to say that psychologicalsafety takes off the brakes that keep people from achieving what’spossible. But it’s not the fuel that powers the car. In any challengingindustry setting, leaders have two vital tasks. One, they must buildpsychological safety to spur learning and avoid preventable failures;two, they must set high standards and inspire and enable people toreach them. Setting high standards remains a crucial management task.So does sharing, sharpening, and continually emphasizing a worthypurpose.

The key insight to take away from this chapter is that in mostworkplaces today it’s simply not possible to ensure excellence byinspecting proverbial widgets. In knowledge work, excellence cannotbe measured easily and simply along the way. More to the point,it’s almost impossible to determine whether people have failed tohit the highest possible standards. It takes time for the results ofuncertain programs to become clear, and reliably measuring goodprocess is difficult. In other words, today’s leaders must motivatepeople to do their very best work by inspiring them, coaching them,


providing feedback, and making excellence a rewarding experience.Motivating and coaching both receive substantial attention already.What I hope you will take away from this chapter is that makingthe environment safe for open communication about challenges,concerns, and opportunities is one of the most important leadershipresponsibilities in the twenty-first century.

Chapter 1 Takeaways

◾ People constantly manage interpersonal risk at work, con-sciously and not, inhibiting the open sharing of ideas,questions, and concerns.

◾ When people don’t speak up, the organization’s ability to inno-vate and grow is threatened.

◾ Psychological safety describes a climate where people feel safeenough to take interpersonal risks by speaking up and sharingconcerns, questions, or ideas.

◾ Leaders of teams, departments, branches, or other groupswithin companies play an important role in shaping psycho-logical safety.

Endnotes

1. Rozovsky, J. “The five keys to a successful Google team.” re:Work Blog.November 17, 2015. https://rework.withgoogle.com/blog/five-keys-to-a-successful-google-team/ Accessed June 13, 2018.

2. Goffman, E. The Presentation of Self in Everyday Life. Overlook Press,1973. Print.

3. Edmondson, A.C. “Managing the risk of learning: Psychological safetyin work teams.” International Handbook of Organizational Teamwork andCooperative Working. Ed. M. West. London: Blackwell, 2003, 255–276.

4. Merchant, N. “Your Silence is Hurting Your Company.” HarvardBusiness Review. September 7, 2011. https://hbr.org/2011/09/your-silence-is-hurting-your-company Accessed June 13, 2018.



https://hbr.org/2011/09/your-silence-is-hurting-your-company

https://hbr.org/2011/09/your-silence-is-hurting-your-company

The Underpinning 23

5. Milliken, F.J., Morrison, E.W., & Hewlin, P.F. “An Exploratory Study ofEmployee Silence: Issues that Employees Don’t Communicate Upwardand Why.” Journal of Management Studies 40.6 (2003): 1453–1476.

6. Edmondson, A.C. “Psychological Safety and Learning Behavior inWork Teams.” Administrative Science Quarterly 44.2 (1999): 350–83.

7. Edmondson, A.C. “Learning from Mistakes Is Easier Said Than Done:Group and Organizational Influences on the Detection and Correctionof Human Error.” The Journal of Applied Behavioral Science 32.1 (1996):5–28.

8. The research assistant, Andy Molinsky, is now an accomplished scholarand Professor of International Management and Organizational Behav-ior at Brandeis University.

9. Schein, E.H. & Bennis, W.G. Personal and Organizational Change throughGroup Methods: The Laboratory Approach. Wiley, 1965. Print.

10. Schein, E.H. “How Can Organizations Learn Faster? The Challengeof Entering the Green Room.” Sloan Management Review 34.2 (1993):85–92. Print.

11. Kahn, W.A. “Psychological Conditions of Personal Engagement andDisengagement at Work.” Academy of Management Journal 33.4 (1990):692–724.


13. Edmondson, A.C. (1999), op cit.14. Todes, D.P. Ivan Pavlov: A Russian Life in Science. Oxford University

Press, 2014. Print.15. Rock, D. “Managing with the Brain in Mind.” strategy+business.

August 27, 2009. https://www.strategy-business.com/article/09306?gko=5df7f Accessed June 13, 2018.

16. Zink, C.F., Tong, Y., Chen, Q., Bassett, D.S., Stein, J.L., &Meyer-Lindenberg, A. “Know Your Place: Neural Processing of SocialHierarchy in Humans.” Neuron 58.2 (2008): 273–83.

17. Edmondson, A.C. & Mogelof, J.P. “Explaining Psychological Safety inInnovation Teams: Organizational Culture, Team Dynamics, or Person-ality?” Creativity and Innovation in Organizational Teams. Ed. L. Thomp-son & H. Choi. Mahwah, NJ: Lawrence Erlbaum Associates Press, 2005:109–36.

18. This is a modified version of the framework first published by Edmond-son, A.C. “The Competitive Imperative of Learning.” Harvard Business

https://www.strategy-business.com/article/09306?gko=5df7f

https://www.strategy-business.com/article/09306?gko=5df7f


Review. July–August, 2008. Print. It was later published in Edmond-son, A.C. Teaming: How Organizations Learn, Innovate, and Compete inthe Knowledge Economy. San Francisco: Jossey-Bass, 2012. Print.

19. Stiehm, J.H. & Townsend, N.W. The U.S. Army War College: MilitaryEducation in a Democracy. Temple University Press, 2002. Print.

20. See Edmondson, A.C. “Psychological Safety and Learning Behavior inWork Teams.” Administrative Science Quarterly 44.2 (1999): 350–83.

2The Paper Trail

“Your greatest fear as a CEO is that people aren’t telling you the truth.”—Mark Costa1

Mark Costa, CEO of Eastman Chemical Company, was speaking to aclassroom full of second-year MBA students at the Harvard BusinessSchool in the late spring of 2018. The students were paying unusu-ally close attention; there was something about his confidence, hisenergy – and indeed his taking the time to share his insights withthem – that exuded “role model.” An alumnus of the school, Costahad spent many years in strategy consulting before taking an exec-utive role at Eastman – from which he was later promoted to runthe company. Now four years into his tenure as CEO, he clearly rel-ished both the opportunity and the responsibility of leading the $10billion-dollar global specialty chemical manufacturer headquarteredin Kingsport, Tennessee. Under Costa’s leadership, the portion ofsales accounted for by innovative specialty products rather than com-modity products had steadily risen, consistent with a crucial strategic

25


goal he’d articulated for the company. Financial performance wascorrespondingly strong. To accomplish this, engaging the expertise,ideas, and market knowledge of Eastman’s 15 000 employees aroundthe world had been mission critical.

For the benefit of the students for whom diplomas and new jobswere imminent, Costa reflected on what he had learned in the quartercentury since he’d graduated from business school. As the quote at theopening of the chapter conveys, he stated – likely surprising many ofthem – that his greatest fear as CEO was of not knowing what’s reallygoing on. He worked hard to make it clear to his employees that hewanted the truth—good, bad, ugly, or disappointing. He explained tothe class that, as a leader, you have to “be willing to be vulnerable andbe open about your mistakes so others feel safe” to report their own.2

Alluding to the risk of hubris, Costa added, “If you think you haveall the answers, you should quit. Because you’re going to be wrong.”3

In today’s organizations, psychological safety is not a “nice-to-have.” It’s not an employee perk, like free lunch or game rooms, thatyou might care about so as to make people happy at work. In con-trast, I’ll argue that psychological safety is essential to unleashing talentand creating value. Hiring talent simply isn’t enough anymore. Peoplehave to be in workplaces where they are able and willing to use theirtalent. In any organization that requires knowledge – and especially inone that requires integrating knowledge from diverse areas of exper-tise – psychological safety is a requirement for success. In short, whencompanies rely on knowledge and collaboration for innovation andgrowth, whether or not to invest in building a climate of psycholog-ical safety is no longer a choice. Every manager must follow MarkCosta’s lead.

Not a Perk

In any company confronting conditions that might be characterizedas volatility, uncertainty, complexity, and ambiguity (VUCA), psy-chological safety is directly tied to the bottom line. This is because

The Paper Trail 27

350

300

250

200

150

100Num

ber

of M

entio

ns

50

0

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

Figure 2.1 Mentions of Psychological Safety in PopularMedia.4

employee observations, questions, ideas, and concerns can providevital information about what’s going on – in the market and in theorganization. Add to that today’s growing emphasis on diversity,inclusion, and belonging at work, and it becomes clear that psy-chological safety is a vital leadership responsibility. It can make orbreak an employee’s ability to contribute, to grow and learn, and tocollaborate.

One measure of practitioner interest in psychological safety canbe found in the term’s use frequency in the popular media. To gaugethe popularity of the concept, I used Factiva to see how many timesthe term had been mentioned in newspapers, articles, blogs, and othernews media. The graph in Figure 2.1 depicts the results, indicatingmentions of “psychological safety” and its variants (i.e. psychologi-cally safe) each year since 1990.

The uptick in mentions in recent years reflects, I believe, growingrecognition that psychological safety matters in any environment inwhich people are attempting to do something novel or challenging.From leading a project team in the office5 to caring for patients inthe hospital ward,6 from coaching a cricket squad on the pitch7 toteaching and counseling young students at school,8 from encouraging


0

100

200

300

400

500

600

70020

01

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

Cita

tions

Figure 2.2 Citations of 1999 Article Introducing TeamPsychological Safety.12

others to speak out about wrong-doing9 to even reaching Mars(!),10

psychological safety is essential for communicating, collaborating,experimenting, and ensuring the well-being of others in a widevariety of team and organizational settings.

Another measure of interest on the part of researchers can befound in academic citations to the article that introduced the conceptand measure of team psychological safety.11 As shown in Figure 2.2,the article has been frequently cited, with each year since its publi-cation in 1999 showing more citations than the year before. This isa quick and simple index of the degree to which academic researchhas found that the psychological safety variable explains outcomes ofinterest.

This chapter reviews the evidence for psychological safety’sbenefits from two decades of research, laying the foundation for thereal-world stories of low and high psychological safety workplacesthat lie ahead in Part II. Over the past 20 years, scholars, consultants,and company insiders have published dozens of rigorous studiesshowing effects of psychological safety in a variety of industrysettings. By sharing some of the highlights, I hope to give the readerconfidence in the importance of psychological safety in the modern

The Paper Trail 29

workplace. My hope is that knowing that the ideas and stories in thisbook are backed up by data will motivate many readers to act on thisknowledge.

The Research

My colleagues and I reviewed the academic literature on psycholog-ical safety. We were surprised by the number of studies we foundand by the range of settings in which psychological safety has beenexamined. Studies conducted in companies, government organiza-tions, nonprofits, school systems, hospitals, and classrooms highlightthe growing cross-sector interest in psychological safety.

Reading more than 100 articles, we found plenty of evidence thatpsychological safety matters. It affects measurable outcomes rangingfrom employee error reporting13 to company return on investment.14

Unfortunately, the research also makes clear that many workplaceslack psychological safety, cutting themselves off from the kinds ofemployee input, engagement, and learning that are so vital to successin a complex and turbulent world.

I organized the studies into five categories. Group 1 reveals theextent to which psychological safety is lacking in many workplaces.Group 2, which is the largest, investigates relationships betweenpsychological safety and learning. In these studies, we find theevidence that psychological safety leads to, among others, creativity,error reporting, and knowledge sharing, as well as behaviors thatdetect the need for change or that help teams and organizations makechange. Group 3 finds positive relationships between psychologicalsafety and performance, and Group 4 finds positive relationshipsbetween psychological safety and employee engagement.

Lastly, Group 5 encompasses what researchers call “moderatorstudies,” in which psychological safety alters a relationship betweenanother team attribute and an outcome, such as team performance.A team attribute might be diverse expertise, which would naturallychallenge the team to figure out how to work effectively. Similarly,


a team with members located in multiple geographic regions mightstruggle to coordinate. Studies show that psychological safety makesit easier for teams to manage such challenges. When people can speakup, ask questions, and get the help they need from each other to sortthings out, they are more likely to overcome the barriers created byworking together across diverse disciplines or time zones.

1. An Epidemic of Silence

Chances are you’ve had the experience at work when you did not aska question you really wanted to ask. Or you may have wanted to offeran idea but stayed quiet instead. Several studies show that these typesof silence are painfully common. Collecting and analyzing data frominterviews with employed adults, studies have investigated when andwhy people feel unable to speak up in the workplace. From this workwe learn, first and foremost, that people often hold back even when theybelieve that what they have to say could be important for the organization, forthe customer, or for themselves.

There is a poignancy in these discoveries. No one gains from thesilence. Teams miss out on insights. Those who fail to speak up oftenreport regret or pain. Some wish they had spoken up. Others rec-ognize they could be experiencing more fulfillment and meaning intheir jobs were they more able to contribute. Those deprived of hear-ing a colleague’s comments may not know what they are missing, butthe fact is that problems go unreported, improvement opportunitiesare missed, and occasionally, tragic failures occur that could have beenavoided.

In an early study of workplace silence, New York University man-agement researchers Frances Milliken, Elizabeth Morrison, and Patri-cia Hewlin interviewed 40 full-time employees working in consult-ing, financial services, media, pharmaceuticals, and advertising, tounderstand why employees failed to speak up at work and what issuesthey failed to raise most often.15 When pressed to explain why theyremained silent, people often said they did not want to be seen in a

The Paper Trail 31

bad light. Another common reason was not wanting to embarrass orupset someone. Still others expressed a sense of futility – along thelines of, “it won’t matter anyway; why bother?” A few mentionedfear of retaliation. But the two most frequently mentioned reasonsfor remaining silent were one, fear of being viewed or labeled neg-atively, and two, fear of damaging work relationships. These fears,which are definitionally the opposite of psychological safety, have noplace in the fearless organization.

What issues employees wanted to speak up about were both orga-nizational and personal. They ranged from concerns that are under-standably difficult to raise: for example, about harassment, a super-visor’s competence, or having made a mistake. More surprisingly,however, they also held back on suggestions for improving a workprocess. In short, as later research would demonstrate more systemat-ically, people at work are not only failing to speak up with potentiallythreatening or embarrassing content, they are also withholding ideasfor improvement. Notably, every individual interviewee reported fail-ing to speak up on at least one occasion. Most had found themselvesin situations where they were very concerned about an issue and yetstill did not raise it to a supervisor.

A later and larger study conducted in a manufacturing companyused survey data to identify very similar reasons for silence.16 Specif-ically, employees who did not feel psychologically safe to speak upcited reasons that included fear of damaging a relationship, lack ofconfidence, and self-protection. In another study, social psychologistRenee Tynan surveyed business school students about their relation-ships with a prior boss to gain insight into when and why peopledo (or don’t) communicate their thoughts upward. She found thatwhen people felt psychologically safe, they spoke up to their bosses.They were able to ask for help and admit errors, despite interpersonalrisk. When they did not feel psychologically safe, they tended to keepquiet or to distort their message so as not to upset their bosses.

A few years ago, University of Virginia Professor Jim Detertand I interviewed more than 230 employees in a large multinationalhigh-tech company.17 We asked interviewees, who spanned all levels,


regions, and functions, to describe instances in which they did anddid not speak up at work to their managers or anyone else higherin the company. Here too, all individuals could readily describea time in which they failed to speak up about something theybelieved mattered. Jim and I combed through the thousands of pagesof accumulated responses to find out what drove people to speakup – and, perhaps more importantly, what drove them to hold back.

Consider the manufacturing technician in a US plant who toldus he didn’t share an idea he had for speeding up the production pro-cess. When we asked why, he replied, “I have kids in college.” At firstglance, a nonsensical reply. But his meaning was clear; he felt he couldnot take the risk of speaking up because he could not afford to lose hisjob. When we probed further, hoping to hear a story about someonelosing a job related to speaking up, the associate admitted that it reallydidn’t work that way. In fact, he replied, “Oh, everyone knows wenever fire anybody.” He was not speaking sarcastically; he was admit-ting that his reticence to rock the boat with what he believed wasa good idea was irrational, and deep down he understood that. Yetthe gravitational pull of silence – even when bosses are well-meaningand don’t think of themselves as intimidating – can be overwhelming.People at work are vulnerable to a kind of implicit logic in which safeis simply better than sorry. Many have simply inherited beliefs fromtheir earliest years of schooling or training. If they stop to think moredeeply, they may realize they’ve erred too far on the side of caution.But that kind of reflection is rarely prompted.

Ultimately, we discovered a small set of common, largelytaken-for-granted beliefs about speaking up at work. We called themimplicit theories of voice. Shown in Table 2.1, they are essentially beliefsabout when it is and isn’t appropriate to speak to higher ups inan organization. To test these implicit theories, gleaned from onecompany, Jim and I conducted a vignette study with managers frommany other companies. We designed fictional vignettes to test whenand if people would employ specific decision rules in determiningwhether or not to speak up. For example, one vignette involved animportant correction an employee wanted to share with the boss; in

The Paper Trail 33

Table 2.1 Taken-for-granted Rules for Voice at Work.

Taken-for-granted RuleGoverning when to Speakor Remain Silent Examples from Interviews

Don’t criticize something theboss may have helpedcreate.

“It’s inherently risky since bosses may feelpersonal ownership of the tasks I amsuggesting are problematic.”

“The boss may have created theseprocesses and may be offended becausehe’s attached to them.”

Don’t speak unless you havesolid data.

“I think that presenting anunder-developed, under-researched ideais never a good idea.”

“You are questioning their ideas and hadbetter have proof to back up yourstatements.”

Don’t speak up if the boss’sboss is present.

“If there is a higher level individualpresent it is risky because you would beafraid that your direct boss would feel asif you were going over their head.”

“My boss would see [speaking up to hisboss] as undermining andinsubordinate.”

Don’t speak up in a groupwith anything negativeabout the work to preventboss from losing face.

“Managers hate to be put on the spot infront of others. It is best to brief themone-on-one so the boss doesn’t lookbad in front of the group.”

“You should pass it by the boss in privatefirst, so you don’t ‘cut his legs out fromunder him.’”

Speaking up brings careerconsequences.

“To stop or criticize a project would be acareer ender at our place.”

“The long-term consequences are badbecause [higher ups] will resent beingput on the spot.”


one of the versions of the vignette, the boss’s boss was present. In theother vignette, only the boss was present. The managers we studiedwere significantly more likely to point out the correction if the boss’sboss was not present.

By and large, these beliefs (taken-for-granted rules) aboutspeaking up make it harder to achieve productivity, innovation,or employee engagement. It’s an old truism that bad news doesn’ttravel up the hierarchy. But what we found is that people err so faron the side of caution at work that they routinely hold back greatideas – not just bad news. They intuitively recognize what Jim andI call the asymmetry of voice and silence. Consider the automaticcalculus that governs speaking up. As depicted in Table 2.2, voice iseffortful and might (but might not) make a real difference in a crucialmoment. Unfortunately, much of the time the potential benefit willtake a while to materialize and might not even happen at all. Silenceis instinctive and safe; it offers self-protection benefits, and these areboth immediate and certain.

Table 2.2 Why Silence Wins in the Voice-SilenceCalculation.

Who BenefitsWhen BenefitOccurs

Certaintyof Benefit

Voice The organization and/or its customers

After some delay Low

Silence Oneself Immediately High

Another way to think about the voice-silence asymmetry is cap-tured in the phrase “no one was ever fired for silence.” The instinctto play it safe is powerful. People in organizations don’t spontaneouslytake interpersonal risks. We don’t want to stumble into a sacred cow.We can be completely confident that we’ll be safe if we are silent, andwe lack confidence that our voices will really make a difference – avoice inhibiting combination.

Another of the implicit theories of voice that Jim and I found thatexplains why people hold back on good ideas, not just bad news, is

The Paper Trail 35

related to a fear of insulting someone higher up in the organization byimplying that the current systems or processes are problematic. Whatif the current system is effectively the boss’s baby? By suggesting achange, we might be calling the boss’s baby ugly. Better to stay silent.

In failing to challenge these widely held taken-for-granted speak-ing rules, employees around the world at this particular company(which, ironically, was dependent on employee expertise and ideas forits future success) were depriving their colleagues of their ideas andingenuity. They were depriving themselves as well – missing out onthe satisfaction of the chance to act on their ideas and create change.Instead of helping to create a learning organization, they were justshowing up and doing their jobs.

2. A Work Environment that Supports Learning

Given this well-documented tendency for people in the workplaceto choose silence over voice, sometimes it seems surprising that any-one ever speaks up at all with potentially sensitive or interpersonallythreatening content. This is where psychological safety comes in.A growing number of studies find that psychological safety can existat work and, when it does, that people do in fact speak up, offer ideas,report errors, and exhibit a great deal more that we can categorize as“learning behavior.”

Learning from Mistakes

For example, in a study of nurses in four Belgian hospitals, a team ofresearchers led by Hannes Leroy explored how head nurses encour-aged other nurses to report errors, while also enforcing high standardsfor safety.18 The challenge here is one of asking people to perform thehighest quality (arguably, error-free) work yet still be willing to talkabout the errors that do occur. Leroy and his colleagues surveyedthe nurses in 54 departments, measuring a set of interrelated factors.


These were psychological safety, error reporting, the actual numberof errors made, and nurses’ beliefs about how much the departmentprioritized patient safety and about whether the head nurse practicedthe safety protocols.

Leroy found that groups with higher psychological safety reportedmore errors to head nurses. That finding was consistent with what Ihad seen back in graduate school in my study of medication errors.19

More interestingly, they found that when nurses thought patient safetywas a high priority in the department and when psychological safetywas high, fewer errors were made. In contrast, when psychologicalsafety was low, despite believing in the department’s professed com-mitment to patient safety, staff made more errors. In short, psycho-logically safe teams made fewer errors and spoke up about them moreoften. What I have found in similar settings is that good leadership (forinstance, on the part of head nurses who demonstrate a commitmentto safety and to openness), together with a clear, shared understand-ing that the work is complex and interdependent, can help groupsbuild psychological safety, which in turn enables the candor that is soessential to ensuring the quality of patient care in modern hospitals.

Quality Improvement: Learn-What and Learn-How

Nearly every organization wants quality improvement. Hospitals,especially, constantly pursue efforts to improve the innumerableprocesses of patient care. Does it make a difference whether a unitsupervisor creates the conditions for psychological safety or simplycommands staff to work on improvement projects?

With Wharton Professor Ingrid Nembhard and Boston Univer-sity Professor Anita Tucker, I studied over a hundred quality improve-ment (QI) project teams in neonatal intensive care units (NICUs) in23 North American hospitals.20 By asking the QI team members toreport on what they did to improve unit processes, we found that theseclustered into two distinct sets of learning behavior, which we calledlearn-what and learn-how. Learn-what described largely independent

The Paper Trail 37

activities like reading the medical literature to get caught up withthe latest research findings. Learn-how, in contrast, was team-basedlearning that included sharing knowledge, offering suggestions, andbrainstorming better approaches.

We were intrigued to find that psychological safety predicted anuptick in learn-how behaviors (those that came with interpersonalrisk) but had no statistical relationship whatsoever with the moreindependent behaviors captured by learn-what activities. This resultprovided a reassuring demonstration that psychological safety doespromote learning by helping people overcome interpersonal risk forengaging in learn-how behaviors. Not surprisingly, for the kinds oflearning that you can do alone (read a book, take an online course),psychological safety is not essential. The results also offer support forwhy psychological safety was not as important in days of yore whenwork might consist primarily of well-defined tasks such as typing let-ters for the boss, or passing the surgeon the correct scalpel.

Reducing Workarounds

“Workarounds,” a phenomenon identified by Anita Tucker in herremarkable ethnographic study of nurses in the early 2000s, are short-cuts that people take at work when they confront a problem thatdisrupts their ability to carry out a required task.21 A workaroundaccomplishes the immediate goal, but does nothing to diagnose orsolve the problem that triggered the workaround in the first place.

The problem with workarounds is that well they, work. Theyseem to get the job done, but, in so doing, they create new, subtle,problems. First, workarounds sometimes create unintended risks orproblems in other areas. For example, confronted with a shortage ofa needed material input (say, linens in a hospital unit), a worker mightsimply find a supply of linens in another unit, thereby getting whatshe needs but depleting her colleagues who will encounter a shortagelater. Second, workarounds delay or prevent process improvement.The problems that trigger workarounds can be seen as small signals of


a need for change in a system or process. The workaround bypassesthe problem, thereby silencing the signal by getting the immediate jobdone – but getting it done in a way that is inefficient over the longerterm. More difficult, because it would require working across silos,would be for nurses to devise a new linen supply system for all units.

Workarounds can occur when workers do not feel safe enoughto speak up and make suggestions to improve the system. Indeed,in another study of hospitals, Jonathon Halbesleben and CherylRathert found that cancer teams with low psychological safety reliedmore on workarounds, while teams with high psychological safetyfocused more on diagnosing the problem and improving the processthat caused it so it didn’t happen again.22 Halbesleben and Rathertgave us additional evidence that psychological safety is important fororganizations interested in achieving process improvement. Theirwork shows that psychological safety makes it easier for people tospeak up about problems and to alter and improve work processesrather than engaging in the counterproductive workarounds.

Another study of process improvement projects, this time ina manufacturing company, also found that projects with greaterpsychological safety were more successful. Here the researchersstudied 52 process-improvement teams following principles of totalquality management (TQM). They found that even when employinga highly-structured process improvement technique, interpersonalclimate matters for success.23

Sharing Knowledge When Confidence Is Low

You might think that speaking up with creative ideas is easier thanspeaking up about errors. Now, imagine you’re at work and you’vegot an idea you’re 95% confident is creative or interesting. You’llprobably have no trouble speaking up. Now imagine that same sit-uation but you’re only 40% confident of your idea. Most people willhesitate, perhaps trying to size up the receptivity of their colleagues.Stated another way, when you feel extremely confident in the value

The Paper Trail 39

or veracity of something you want to say, you are more likely to sim-ply open your mouth and say it. But when your confidence in youridea or your knowledge is low, you might hold back.

In a particularly compelling study in several US manufacturingand service companies, University of Minnesota Professor EnnoSiemsen and his colleagues found an intuitively interesting relation-ship between confidence and psychological safety.24 As expected,the more confident people were in their knowledge, the morethey spoke up. More interestingly, a psychologically safe workplacehelped people overcome a lack of confidence. In other words, ifyour workplace is psychologically safe, you’re more able to speakup even when you have less confidence. Given that an individual’sconfidence and the value of his idea are not always tightly linked, theusefulness of psychological safety for facilitating knowledge sharingcan be immense. Communication frequency among coworkers alsoled to psychological safety. In other words, the more we talk to eachother, the more comfortable we become doing so.

3. Why Psychological Safety Mattersfor Performance

To understand why psychological safety promotes performance, wehave to step back to reconsider the nature of so much of the work intoday’s organizations. With routine, predictable, modular work on thedecline, more and more of the tasks that people do require judgment,coping with uncertainty, suggesting new ideas, and coordinating andcommunicating with others. This means that voice is mission criti-cal. And so, for anything but the most independent or routine work,psychological safety is intimately tied to freeing people up to pursueexcellence.

When I set out to study 50 teams – including sales, production,new product development, and management teams – in a manufac-turing company in the mid 1990s, my goal had been to establisha relationship between psychological safety and learning behavior.While I was at it, I measured performance. I did this in two ways:


The first was self-report, meaning team members confidentially ratedtheir team’s performance on a scale of one to seven. The other wassomewhat more objective. I asked managers who evaluated the team’swork, along with (internal) customers who received the work, to rateeach team’s performance on a similar scale, also with complete con-fidentially. Happily, the data showed that teams with psychologicalsafety also had higher performance – a result that held for both typesof performance measures.25

Researchers Markus Baer and Michael Frese took this questionup to the next level of analysis by showing that psychological safetyincreased company performance in a sample of 47 mid-size Germanfirms in both industrial and services industries. Performance was mea-sured in two ways: longitudinal change in return on assets (holdingprior return on assets constant) and executive ratings of companygoal achievement.26 All of the companies were engaged in processinnovations. But process innovation efforts only led to higher per-formance when the organization had psychological safety. In short,process innovation can be a good way to boost firm performance, buta psychologically safe environment helps the investment pay off.

Research also shows a relationship between psychological safetyand innovation. For instance, Chi-Cheng Huang and Pin-ChenJiang collected survey data from 245 members of 60 Research andDevelopment (R&D) teams in several Taiwanese technology firmsand found that psychologically safe teams outperformed others.27

Without psychological safety, the researchers explained, teammembers were unwilling to offer their ideas or knowledge becauseof the fear of being rejected or embarrassed. They emphasized theparticular importance of psychological safety for teams in R&Dbecause they necessarily have to take risks and confront failure beforethey achieve success.

Finally, a multi-year study of teams at Google, code-namedProject Aristotle, found that psychological safety was the criticalfactor explaining why some teams outperformed others, as reportedin a detailed feature article by Charles Duhigg in the New York TimesMagazine in 2016, and widely discussed in the blogosphere.28 Google

The Paper Trail 41

researchers from the company’s sophisticated “people analytics”group reviewed the academic literature on team effectiveness. Theirfirst line of attack was to consider team composition – a variableconsidered important in historical research on teams, primarily interms of whether the skills team members hold are a good match forthe work they’re expected to do.

Led by Julia Rozovsky, the researchers considered people’s edu-cational backgrounds, hobbies, friends, personality traits and more,in their analysis a set of 180 teams from all over the company. Theyfound nothing. No mix of personality types or skills or backgroundsemerged that helped explain which teams performed well andwhich didn’t. It seemed like there was no answer to the questionof why some teams thrive and others fail. And then, as Duhiggwrote, “When Rozovsky and her Google colleagues encounteredthe concept of psychological safety in academic papers, it was as ifeverything suddenly fell into place.”29 What they had discovered wasthat even the extremely smart, high-powered employees at Googleneeded a psychologically safe work environment to contribute thetalents they had to offer. The team also found four other factorsthat helped explain team performance – clear goals, dependablecolleagues, personally meaningful work, and a belief that the workhas impact. As Rozovsky put it, however, reiterating the quote atthe start of Chapter 1, “psychological safety was by far the mostimportant . . . it was the underpinning of the other four.”30

4. Psychologically Safe Employees Are EngagedEmployees

Executive interest in employee engagement has taken hold in recentyears, building on the longtime focus on employee satisfaction as animportant measure for predicting turnover. Today, most managersunderstand that employee satisfaction is important but incomplete.Satisfaction, which refers to how happy or content employees are,doesn’t capture emotional commitment to the work, or motivation


to pour oneself into doing a good job. Engagement, defined as theextent to an employee feels passionate about the job and committed tothe organization, is seen as an index of willingness to put discretionaryeffort into one’s work. Validated measures of employee engagementare widely available, and most executives recognize employee engage-ment as a vital element of strong company performance.

Recent studies of employee engagement include attentionto psychological safety. For instance, a study in a Midwesterninsurance company found that psychological safety predicted workerengagement. In turn, psychological safety was fostered by supportiverelationships with coworkers.31 Another study looked at the rela-tionship between employee trust in top management and employeeengagement. With survey data from 170 research scientists workingin six Irish research centers, the authors showed that trust in topmanagement led to psychological safety, which in turn promotedwork engagement.32 Finally, a study of Turkish immigrants employedin Germany found that psychological safety was associated with workengagement, mental health, and turnover intentions. Moreover, theyfound that the positive effects of psychological safety were higherfor the immigrants than for the German employees in the samecompany.33

One place where worker engagement really matters is healthcaredelivery. Frontline staff confront high stress and emotionally ladenwork with life and death consequences. Disengaged employees leadto safety risks and to staff turnover. Turnover means higher recruitingand training costs, as well as a higher percentage of less experiencedworkers on staff. Experts’ concerns about staff turnover have thusgiven rise to interest in improving the healthcare work environmentas a strategy for employee retention. In one recent study, a survey ofclinical staff at a large metropolitan hospital found that psychologicalsafety was related to commitment to the organization and to patientsafety. The authors noted that a work environment in which work-ers felt safe to speak up about problems was especially important inhealthcare for helping people feel able to provide safe care and stayengaged in the work.34

The Paper Trail 43

5. Psychological Safety as the Extra Ingredient

The fifth and final group of studies emphasizes psychological safety’srole in altering the strength of relationships between other variables.In these studies, psychological safety acts (using statistical language)as a moderator that makes other relationships weaker or stronger.Psychological safety has been found to help teams overcome the chal-lenges of geographic dispersion, put conflict to good use, and leveragediversity.

Overcoming Geographic Dispersion

It’s increasingly common for teams to have members working in dif-ferent locations around the world who may not even have met inperson. These so-called virtual teams face the related challenges ofcommunicating through electronic media, managing national culturaldiversity, coping with time zone differences, and dealing with shift-ing membership over time. Psychological safety has been shown tohelp such teams manage these challenges. For instance, in an ambi-tious study of 14 innovation teams with members dispersed across18 nations, University of Western Australia Professor Cristina Gibsonand Rutgers University Professor Jennifer Gibbs showed that psycho-logical safety helped these dispersed teams navigate the challenges ofdispersion.35 With psychological safety, team members felt less anx-ious about what others might think of them and were better able tocommunicate openly.

Putting Conflict to Good Use

Conflict is another challenge most teams confront – whether theywork face to face or spread around the globe. In theory, conflictpromotes better decision-making and fosters innovation because itensures consideration of diverse views and perspectives. In practice,


however, people are not always good at navigating conflict and puttingit to good use.36 It’s easy to get upset or dig in one’s heels, effec-tively squandering the opportunity to improve the work by workingthrough differences. Some recent research has found that psycho-logical safety can make the difference between conflict being put togood use and conflict getting in the way of team performance. Forinstance, in a study of 117 student project teams, Bret Bradley and hiscolleagues showed that psychological safety moderated the relation-ship between conflict and performance such that conflict led to goodteam performance when teams had high psychological safety and lowperformance otherwise.37 They attributed this result to the ability toexpress relevant ideas and critical discussion without embarrassmentor excessive personal conflict between team members.

As you can see, studies that look at psychological safety have beendone in many settings, including factories, hospitals, and classrooms.Yet it is also the case that executives wrestling with strategic deci-sions can benefit from attention to creating a climate of curiosity andcandor – in other words, psychological safety. When I studied topmanagement teams with action scientist Diana Smith, we analyzeddetailed transcripts of their conversations to show how a psycholog-ically safe climate for candid discussion of strategic disagreement canbe created, even in high-level teams confronting strategic challenges,and how this can enable productive decision-making.38

Gaining Value from Diversity

Teams are often put together to leverage diverse expertise. But toooften, the challenge of integrating diverse knowledge, perspectives,and skills is underestimated, and the hoped-for synergy never mate-rializes. One recent study showed that psychological safety can makeor break achievement of team performance in diverse teams. Theresearchers surveyed master’s students participating in 195 teams in aFrench university and found that expertise-diverse teams performedwell when psychological safety was high and badly otherwise.39

The Paper Trail 45

Finally, a number of studies have investigated effects of demo-graphic diversity on team performance. Some have shown that diver-sity helps performance, while others have found a negative relation-ship between diversity and performance. When different studies showconflicting results like this, it’s usually a sign of a missing moderator.In this case, psychological safety could be that missing ingredient –the factor that could make or break a diverse team’s ability to putits different perspectives to good use. Indeed, in one study in aMidwestern mid-size manufacturing company, a positive climate fordiversity and psychological safety together led to more discretionaryeffort. These relationships were stronger for minorities than forwhites, suggesting that psychological safety may be playing anespecially crucial role for minorities in creating engagement and afeeling of being valued at work.40

Bringing Research to Practice

The research summarized here, which is steadily growing with con-sistent observations across diverse industry settings, provides furtherconfidence that psychological safety truly offers benefits for orga-nizations and countries around the world. No longer confined toacademic interest, psychological safety has garnered attention frompractitioners in almost every industry – especially in the aftermathof Google’s Project Aristotle, with its feature pieces in the New YorkTimes and on Fareed Zakaria GPS on CNN.41 More and more pro-fessionals – consultants, managers, physicians, nurses, engineers – canbe found talking about psychological safety. Yet few may be awareof the full weight of supporting evidence that it matters. And fewerstill may have stopped to reflect on what their companies lose whenpsychological safety is missing.

One of the most important things to keep in mind, whereveryou work, is that the failure of an employee to speak up in a crucialmoment cannot be seen. This is true whether that employee is on thefront lines of customer service or sitting next to you in the executive


board room. And because not offering an idea is an invisible act, it’shard to engage in real-time course correction. This means that psy-chologically safe workplaces have a powerful advantage in competitiveindustries.

The four chapters ahead in Part II vividly portray the conse-quences of workplace fear (Chapters 3 and 4) and the benefits ofpsychological safety (Chapters 5 and 6) for both organizational perfor-mance and human safety. We’ll visit more than 20 organizations – oldand new, large and small, private and public sector, domestic and over-seas. Examining events that transpired in companies as diverse as Volk-swagen and Wells Fargo, I hope to convey a visceral understanding ofwhat is lost in fear-based workplaces, which are, alas, all too often stillthe default in organizations around the world, even after two decadesof research providing evidence of its costs. Taking a look inside a rangeof fearless organizations, such as Pixar Animation Studios and DaVitaKidney Centers, I also hope to convey all that is gained.

Chapter 2 Takeaways

◾ Psychological safety is not a perk; it’s essential to producinghigh performance in a VUCA world.

◾ Psychological safety is too often missing in today’s organizations◾ Twenty years of research on psychological safety finds positive

benefits for learning, engagement, and performance in a widerange of organizations.

Endnotes

1. Mark Costa, CEO of Eastman Chemical, HBS class comments, April18, 2018.

2. Ibid.3. Ibid.4. The data in this chart comes from a Factiva search, conducted May 25,

2018. Factiva, Inc. is a business information and research tool owned

The Paper Trail 47

Dow Jones & Company. Factiva provides access to more than 30,000sources, such as newspapers, journals, magazines, and more from nearlyevery country in the world. Thus, the search was quite comprehensive.

5. Corcoran, S. “A good boss makes for a happy team.” The Sunday Times.September 24, 2017. https://www.thetimes.co.uk/article/a-good-boss-makes-for-a-happy-team-r30ndjjfv Accessed June 13, 2018.

6. Blumental, D. & Ganguli, I. “Patient Safety: Conversation to Curricu-lum.” The New York Times. January 26, 2010. https://www.nytimes.com/2010/01/26/health/26error.html Accessed June 13, 2018.

7. “Six and Out? What Australia’s cricket scandal tells us about the sixgolden rules of integrity.” The Mandarin, March 28, 2018. https://www.themandarin.com.au/90552-australian-cricket-scandal-six-golden-rules-integrity/ Accessed June 13, 2018.

8. Vander Ark, T. “Promoting Psychological Safety in Classrooms forStudent Success.” GettingSmart.com, December 29, 2016. http://www.gettingsmart.com/2016/12/promoting-psychological-safety-in-classrooms/ Accessed June 13, 2018.

9. Wallace, K. “After #MeToo, more women feeling empowered.”CNN Wire, December 27, 2017. https://www.cnn.com/2017/12/27/health/sexual-harassment-women-empowerment/index.htmlAccessed June 13, 2018.

10. Landon, L.B., Slack, K.J., & Barrett, J.D. “Teamwork and Collabora-tion in Long-Duration Space Missions: Going to Extremes.” AmericanPsychologist 73.4 (2018): 563–575.


12. This citation data was obtained from Google Scholar, accessed May 25,2018.

13. Frese, M. & Keith, N. “Action Errors, Error Management, andLearning in Organizations.” Annual Review of Psychology 66.1 (2015):661–87.

14. Baer, M. & Frese, M. “Innovation Is Not Enough: Climates for Initiativeand Psychological Safety, Process Innovations, and Firm Performance.”Journal of Organizational Behavior 24.1 (2003): 45–68.

15. Milliken, F.J., Morrison, E.W., & Hewlin, P.F. “An Exploratory Study ofEmployee Silence: Issues That Employees Don’t Communicate Upwardand Why.” Journal of Management Studies 40.6 (2003): 1453–76.

16. Brinsfield, C.T. “Employee Silence Motives: Investigation of Dimen-sionality and Development of Measures.” Journal of Organizational Behav-ior 34.5 (2013): 671–97.

https://www.thetimes.co.uk/article/a-good-boss-makes-for-a-happy-team-r30ndjjfv

https://www.thetimes.co.uk/article/a-good-boss-makes-for-a-happy-team-r30ndjjfv

https://www.nytimes.com/2010/01/26/health/26error.html

https://www.nytimes.com/2010/01/26/health/26error.html

https://www.themandarin.com.au/90552-australian-cricket-scandal-six-golden-rules-integrity



http://gettingsmart.com

http://www.gettingsmart.com/2016/12/promoting-psychological-safety-in-classrooms



https://www.cnn.com/2017/12/27/health/sexual-harassment-women-empowerment/index.html

https://www.cnn.com/2017/12/27/health/sexual-harassment-women-empowerment/index.html


17. Detert, J.R. & Edmondson, A.C. “Implicit Voice Theories: Taken-for-Granted Rules for Self-Censorship at Work.” The Academy of Manage-ment Journal 54.3 (2011): 461–88.

18. Leroy, H., Dierynck, B., Anseel, F., Simons, T., Halbesleben, J.R.B.,McCaughey, D., Savage, G.T., & Sels, L. “Behavioral Integrity forSafety, Priority of Safety, Psychological Safety, and Patient Safety: ATeam-Level Study.” Journal of Applied Psychology 97.6 (2012): 1273–81.


20. Tucker, A.L., Nembhard, I.M., & Edmondson, A.C. “ImplementingNew Practices: An Empirical Study of Organizational Learning in Hos-pital Intensive Care Units.” Management Science 53.6 (2007): 894–907.

21. Tucker, A.L. & Edmondson, A.C. “Why hospitals don’t learn fromfailures: Organizational and psychological dynamics that inhibit systemchange.” California Management Review 45.2 (2003): 55–72.

22. Halbesleben, J.R.B. & Rathert, C. “The Role of Continuous QualityImprovement and Psychological Safety in Predicting Work-Arounds.”Health Care Management Review 33.2 (2008): 134–144.

23. Arumugam, V., Antony, J., & Kumar, M. “Linking Learning andKnowledge Creation to Project Success in Six Sigma Projects: AnEmpirical Investigation.” International Journal of Production Economics141.1 (2013): 388–402.

24. Siemsen, E., Roth, A.V., Balasubramanian, S., & Anand, G. “TheInfluence of Psychological Safety and Confidence in Knowledge onEmployee Knowledge Sharing.” Manufacturing & Service OperationsManagement 11.3 (2009): 429–47.

25. Edmondson, A.C. (1999), op cit.26. Baer, M. & Frese, M. (2003), op cit.27. Huang, C., & Jiang, P. “Exploring the Psychological Safety of R&D

Teams: An Empirical Analysis in Taiwan.” Journal of Management &Organization 18.2 (2012): 175–92.

28. Duhigg, C. “What Google Learned From Its Quest to Build thePerfect Team.” The New York Times Magazine, February 25, 2016.https://www.nytimes.com/2016/02/28/magazine/what-google-learned-from-its-quest-to-build-the-perfect-team.html Accessed June13, 2018.

29. Ibid.



The Paper Trail 49

30. Rozovsky, J. “The five keys to a successful Google team.” re:Work Blog.November 17, 2015. https://rework.withgoogle.com/blog/five-keys-to-a-successful-google-team/ Accessed June 13, 2018.

31. May, D.R., Gilson, G.L., & Harter, L.M. “The Psychological Condi-tions of Meaningfulness, Safety and Availability and the Engagement ofthe Human Spirit at Work.” Journal of Occupational and OrganizationalPsychology 77.1 (2004): 11–37.

32. Chughtai, A. A. & Buckley, F. “Exploring the impact of trust on researchscientists’ work engagement.” Personnel Review 42.4 (2013): 396–421.

33. Ulusoy, N., Mölders, C., Fischer, S., Bayur, H., Deveci, S., Demiral,Y., & Rössler, W. “A Matter of Psychological Safety: Commitment andMental Health in Turkish Immigrant Employees in Germany.” Journalof Cross-Cultural Psychology 47.4 (2016): 626–645.

34. Rathert, C., Ishqaidef, G., May, D.R. “Improving Work Environmentsin Health Care: Test of a Theoretical Framework.” Health Care Manage-ment Review 34.4 (2009): 334–343.

35. Gibson, C.B. & Gibbs, J.L. “Unpacking the Concept of Virtuality: TheEffects of Geographic Dispersion, Electronic Dependence, DynamicStructure, and National Diversity on Team Innovation.” AdministrativeScience Quarterly 51.3 (2006): 451–95.

36. Edmondson, A.C. & Smith, D.M. “Too Hot to Handle? How to Man-age Relationship Conflict.” California Management Review 49.1 (2006):6–31.

37. Bradley, B.H., Postlethwaite, B.E., Hamdani, M.R., & Brown, K.G.“Reaping the Benefits of Task Conflict in Teams: The Critical Role ofTeam Psychological Safety Climate.” Journal of Applied Psychology 97.1(2012): 151–58.

38. Edmondson, A.C. & Smith, D.M. (2006), op cit.39. Martins, L.L., Schilpzand, M.C., Kirkman, B.L., Ivanaj, S., & Ivanaj, V.

“A Contingency View of the Effects of Cognitive Diversity on TeamPerformance: The Moderating Roles of Team Psychological Safety andRelationship Conflict.” Small Group Research 44.2 (2013): 96–126.

40. Singh, B., Winkel, D.E., & Selvarajan, T.T. “Managing Diversity atWork: Does Psychological Safety Hold the Key to Racial Differencesin Employee Performance?” Journal of Occupational and OrganizationalPsychology 86.2 (2013): 242–63.

41. “How to Build the Perfect Team.” Fareed Zakaria GPS. CNN, April17, 2016. https://archive.org/details/CNNW_20160417_170000_Fareed_Zakaria_GPS Accessed June 1, 2018.



https://archive.org/details/CNNW_20160417_170000_Fareed_Zakaria_GPS

https://archive.org/details/CNNW_20160417_170000_Fareed_Zakaria_GPS

PART

II Psychological Safetyat Work

3Avoidable Failure

“I feel misused by my own company.”—Oliver Schmidt, Volkswagen engineer1

“Until I know what my boss thinks, I don’t want to tell you.”—Regulator, Federal Reserve Bank of New York (FRBNY)2

In May 2015, the Volkswagen Group had every reason to feel proud.3

It had sold over 10 million vehicles the previous year, thereby lay-ing claim to the title of world’s largest automaker. One of the largestemployers in Germany, the company was credited with helping thecountry recover from the global financial crisis of 2008. Ironically, asit would turn out, its Jetta TDI Clean Diesel won the Green Car ofthe Year at the 2008 Los Angeles Auto Show. A firm with a 78-yearhistory in Germany, made famous by the iconic Beetle of the 1960s,and with a pristine reputation for engineering prowess, Volkswagen’sstar shone bright enough to be blinding.

As the saying goes, pride cometh before the fall. Merely monthslater, Volkswagen (VW), the world’s largest automotive company,

53

54 Psychological Safety at Work

was facing unimaginable scandal. The clean diesel engines that hadanchored its impressive US sales were discovered to have been –essentially – a hoax. German officials raided the company headquar-ters in Wolfsburg, searching for incriminating evidence. Criminalinvestigations were opened by the United States and the EuropeanUnion to figure out who knew what, when, and how. The companyhalted sales, reported its first quarterly loss in 15 years, and witnesseda third of its market value vanish. CEO Martin Winterkorn resignedin September of 2015, taking “full responsibility” while denying“wrongdoing,” and at least nine senior managers were suspended orput on leave.4

In the following years, prosecutors in the United States and Ger-many would identify more than 40 people, “spread out across at leastfour cities and working for three VW brands” involved an elaboratescheme to defraud government regulators.5 “Dieselgate,” as the scan-dal was dubbed, referred to VW’s deceptiveness in complying withthe regulations required by the US Environmental Protection Agency(EPA) to sell automobiles in the United States.

Exacting Standards

How could this have happened? When Winterkorn had taken thehelm in 2007, he’d set a goal that was both precise and ambitious:to triple the company’s US sales within 10 years, thereby surpassingrivals Toyota and General Motors to become the world’s largest auto-mobile maker. The company’s so-called clean diesel vehicles, toutedfor their high performance and excellent fuel economy, were essentialto this strategy. There was only one problem: diesels produced morenitrous oxide (NOx) than gasoline engines and would not pass theUnited States environmental regulations. As VW manager-engineerWolfgang Hatz admitted in 2007 about the challenge to create cleandiesel for the US market, “The CARB [California Air ResourcesBoard] is not realistic. We can do quite a bit, and we will do quite abit. But impossible we cannot do.”6

Avoidable Failure 55

Hatz and his engineering colleagues then went to work. Some-where in the millions of lines of software code they wrote for whatbecame the “clean diesel” vehicles, they embedded instructions thatwould enable the cars to pass the strict US emissions tests. Conceptu-ally, the trick was simple enough. The engineers designed and imple-mented software that could determine when a vehicle was undergoingstandard emissions testing in a lab, in which case only two wheelsrotated, as opposed to four wheels when the vehicle was driven on theroad. When tested in a lab, the diesel engines complied with accept-able NOx levels. However, that compliance sacrificed performanceand fuel economy, which made the cars unacceptable to consumers.That’s why the software directed the exhaust control equipment tostop working once the vehicle was off the regulators’ test beds. On theroad, the so-called clean diesel engines spewed into the atmosphereas much as 40 times the level of NOx permitted by regulations.7

For nearly 10 years, all appeared to be going well. The defeatdevices, as they were later called, enabled VW to reach its ambitioussales goals four years ahead of its target date.8 In 2013, an interna-tional nonprofit group, partnering with engineers at West VirginiaUniversity’s Center for Alternative Fuels, Engines, and Emissions,along with California environmental regulators, became interestedin how diesel engines performed. They decided to compare in-laband on-road emissions and mileage performances on several typesof diesel vehicles, including those of Volkswagen. Soon enough, thedefeat device came to light. For the next two years, the US envi-ronmental agencies presented their findings, VW denied, covered up,and finally confessed. Winterkorn then resigned, saying, “I am notaware of any wrongdoing on my part.”9 Across VW’s brands, about11 million of the diesel vehicles worldwide would be discovered tohave the cheating device installed.

How could this failure have been avoided? It’s natural to want topoint a finger at someone, or at a small group, to hold responsible for,at the very least, the 59 unnecessary deaths and 30 cases of chronicbronchitis that researchers estimated are the result of VW’s deceptiveemissions practices.


Martin Winterkorn is certainly a good candidate to be cast as thevillain. He had a reputation as an arrogant, perfectionistic martinetwith an obsessive attention to detail. As one executive at VW toldreporters, “There was always a distance, a fear and a respect . . . Ifhe [Winterkorn] would come and visit or you had to go to him,your pulse would go up. If you presented bad news, those were themoments that it could become quite unpleasant and loud and quitedemeaning.” Other managers cited instances when Winterkornblamed engineers for paint that exceeded regulations by less than amillimeter, or for not offering a specific shade of red that was sellingwell on competitors’ models.10 A video shot at the Frankfurt motorshow in 2011 and widely viewed on YouTube shows Winterkorn’sirritation at discovering that Hyundai, a so-called lesser automotivebrand, had managed to engineer a steering wheel that was silentwhen adjusted from the driver’s seat – a feat VW had been unableto master.11 “Bischoff!” barks Winterkorn, as if to lay the blame onhis design chief, Klaus Bischoff, and voices displeasure that a rivalcompany managed to get rid of the “clonking sound.”

Yet, there are reasons to question this temptingly simple explana-tion with its singular villain. First, many organizational leaders gen-uinely believe that “no news” means that things are going well. Theyassume that if people were struggling to implement some directive oranother, they would speak up and push back. They take for grantedthat their own voices are welcome and fail to appreciate that othersmight feel unable to bring bad news up the chain of command. Forsure, this kind of blindness does not constitute effective leadership,but it also cannot be called villainous. Second, and more specific tothis case, Winterkorn’s leadership was not born in a vacuum. He wasthe protégé of the immensely powerful Ferdinand Piech, VW’s for-mer chairman, CEO, and top shareholder. A brilliant and visionaryautomotive engineer, Piech had been convinced that terrorizing sub-ordinates was the way to achieve profitable design. Chrysler executiveBob Lutz recounted a conversation he had with Piesch at an industrydinner in the 1990s. When Lutz expressed admiration for the exte-rior design of Volkswagen’s new model Golf and wished for similar


success at Chrysler, Piech offered up an explanation that might serveas a textbook example of how to create a psychologically unsafe envi-ronment while seeking to motivate:

I’ll give you the recipe. I called all the body engineers, stamping people,manufacturing, and executives into my conference room. And I said, “I amtired of all these lousy body fits. You have six weeks to achieve world-classbody fits. I have all your names. If we do not have good body fits in sixweeks, I will replace all of you. Thank you for your time today.12

Writing soon after VW’s fall, Lutz speculated that Piech was“more than likely the root cause of the VW diesel-emissionsscandal” because he instigated “a reign of terror and a culture whereperformance was driven by fear and intimidation.”13 Althoughperhaps an extreme case, the fact is that many managers are sym-pathetic to the use of power to insist that people achieve certaingoals – offering clear metrics and deadlines. The belief that peoplemay not push themselves hard enough without a clear understandingof the negative consequences of failing to do so is widespread andeven taken for granted by many in management roles, along withjust as many casual onlookers contemplating human motivationat work. What many people do not realize is that motivation byfear is indeed highly effective – effective at creating the illusion thatgoals are being achieved. It is not effective in ensuring that peoplebring the creativity, good process, and passion needed to accomplishchallenging goals in knowledge-intensive workplaces.

But even Piech was not, as Lutz remarked, the “root cause” ofDieselgate. Just as CEO Martin Winterkorn’s beliefs about how bestto motivate people were learned from his mentor, Ferdinand Piech,Piech’s management beliefs were learned from his mentor – hisgrandfather, Ferdinand Porsche, who had been the brilliant leadengineer for the Beetle. Nor was Herr Porsche the root cause.Porsche, for his part, was hugely inspired in his efforts by HenryFord and in the mid-1930s traveled to Detroit to study Ford’s RiverRouge factory complex, eventually using what he’d learned tobuild the first automotive assembly line in Germany.14 This was


still the golden age for the manufacturing industry, when fear andintimidation were, arguably, a proven managerial technique tomotivate speed and accuracy in factory workers. When authoritativedemands, combined with process improvements, could reduce anautomobile’s assembly line production time from 12 hours to 3, asFord’s factory did, the company’s profits were real.

The root cause of VW’s Dieselgate scandal in 2015 cannot belocated in the personality or leadership of any single person or smallgroup. Perhaps one could say the failure was caused by holdingfast to an outdated belief about what motivates workers. A scenein Charlie Chaplin’s classic film Modern Times parodies what suchold-fashioned motivation-by-fear can look like. Chaplin plays anassembly line worker who fails to keep pace tightening the widgetsas they appear before him on the moving belt, only to be kicked bya coworker, chastised and hit by a manager, and ordered to increasespeed by an executive.15 Today, when simple tasks have increasinglybecome automated and knowledge workers do not tighten widgetsbut rather collaborate, synthesize, make decisions, and continuallylearn, such methods seem especially comedic.

Interestingly, Bischoff, the designer who was chastised by Win-terkorn for the clonking steering shaft, defended this managementstyle, telling a reporter, “Of course [Winterkorn] went through theroof when something went wrong . . . ” and excused the behavior bypointing out that his boss could also be “extremely human with a softspot for people’s personal fates.”16 What’s at stake here isn’t whetheror not a CEO is extremely human or not. Winterkorn’s kindnessand “soft spots” were likely within a normal range when measuredagainst other human beings. What’s at stake is what he believed wasthe best way to motivate employees – and the relevance of these beliefsfor today’s work. Given what we now know about the relationshipbetween psychological safety and learning, a leader who threatens tofire managers and engineers if they do not come up with world-classbody fits in six weeks seems best cast in a silent film.

Like the noxious fumes the faulty VW diesel engines emitted, lowpsychological safety affects everyone who breathes it in. As Professor


Ferdinand Dudenhoffer, an automotive expert of at the Universityof Duisburg-Essen, put it “ . . . there is a special pressure at VW.”17

The company’s governance dynamics contributed to that special pres-sure. According to Dudenhoffer, unlike at other German automobilemanufacturers, where the supervisory board ultimately controlled theCEO, at VW the board held “no such authority.”18 That may bebecause relatives of the founding Porsche family held a quarter of the20 board seats; two seats were held by regional politicians, eager todo whatever it took to keep jobs in the region, and two were held byrepresentatives of Qatar’s sovereign wealth fund.

Given this insidious culture of fear, it’s unsurprising that whenfaced with a seemingly insurmountable technical obstacle – to pro-duce a diesel engine that could pass US environmental testing – andpressed for a solution that could meet the company’s target goals,engineers and regulatory officials at VW decided to find a way. How-ever clever and lucrative the idea may have seemed at the time, andhowever much VW’s sales and reputation soared, history has shownus that it was not, in the long run, a viable solution.

At least one member of the supervisory board was unafraidto speak up. Bernd Osterloh, 1 of the 10 elected members whorepresented employees (comparable to union representatives in theUS), sent a telling letter to the VW staff on September 24, 2015,shortly after the US regulators revealed the cheating. As if citingcentral tenets of psychological safety, Osterloh wrote, “we need inthe future a climate in which problems aren’t hidden but can beopenly communicated to superiors. We need a culture in which it’spossible and permissible to argue with your superior about the bestway to go.”19

After the emissions scandal broke, Winterkorn claimed the com-pany needed stricter rules to make sure this kind of deceit did nothappen again. But it’s unclear how stricter rules would have engi-neered an environmentally safe diesel engine or enabled the companyto reach its goal to become the world’s largest car company. In retro-spect, the goal itself seems suspect. Could failure have been avoided ifthe engineers, working in a psychologically safer environment, could


report back the “bad news” that attaining a clean diesel engine underthe terms demanded was simply not feasible?

Perhaps most stunning thing about the VW emissions debacle isthat it’s by no means a singular event. The same script – unreachabletarget goals, a command-and-control hierarchy that motivates by fear,and people afraid to lose their jobs if they fail – has been repeated againand again. In part that’s because it’s a script that was useful in the past,when goals were reachable, progress directly observable, and taskslargely individually executed. Under those conditions, people couldbe compelled to reach them simply by fear and intimidation. Theproblem is that, in today’s volatile, uncertain, complex, and ambigu-ous (VUCA) world, this is no longer a script that’s good for business.Rather than success, it’s a playbook that invites avoidable, and oftenpainfully public, failure.

In the rest of this chapter, we will see a similar script play outin three other organizations: Wells Fargo, Nokia, and the FederalReserve Bank of New York. In each of these cases, a psychologicallyunsafe culture appeared to be working for some period of time, but,like a ticking bomb, it eventually exploded from within, decimatingreputations of once-venerated companies.

Stretching the Stretch Goal

A year before its notorious fall, Wells Fargo could still call itself themost valuable bank, ranking first in market value among all US banksand serving roughly one in three American households.20 Rated byBarron’s as one of the “world’s most respected companies,” the lion’sshare of Wells Fargo’s success stemmed from its Community Bankingdivision; in 2015, with over 6000 local branches across the US, thedivision accounted for over half the company’s revenue.21 Commu-nity Banking provided a range of financial services, including check-ing and savings accounts, loans, and credit cards, to households andsmall businesses.


Community Banking relied heavily on cross-selling, the practiceof selling existing customers additional products, for its growth strat-egy. Wells Fargo believed it could gain a competitive advantage in thebanking industry by becoming a one-stop shop for all of its customers’financial needs. The bank took pride in its ability to sell its customersadditional products. In fact, in his 2010 letter to shareholders, CEOJohn Stumpf boasted that the company was “the king of cross-sell.”22

By 2015, Wells Fargo’s claim to that title seemed strong: it was aver-aging 6.11 products per customer, compared to the industry averageof 2.71.23

Yet superior cross-selling was to Wells Fargo what clean diesel wasto the Volkswagen Group: involving an ultimately unattainable targetgoal that was nonetheless demanded of employees by the company’stop leaders upon penalty of job loss.

By September 8, 2016, it was all over. The ticking time bombhad exploded from within, shattering the king of cross-sell’s illusoryone-stop shop. After having been found guilty of widespread miscon-duct in sales practices in its Community Banking division, Wells Fargoannounced a $185 million settlement with the Consumer FinancialProtection Bureau (CFPB) and two other US regulatory agencies.John Stumpf resigned the following month.24

What happened at Wells Fargo was both predictable and avoid-able. And it could not have persisted as long as it did without apsychologically unsafe culture. Let’s look more closely at how eventsunfolded.

In the early 2000s, Wells Fargo had adopted a cross-selling cam-paign called “Going for Gr-Eight,” meant to motivate CommunityBanking employees to sell, on average, a previously unheard ofeight products per customer. To accomplish this, incentive schemeswere put in place up and down the hierarchy: personal bankers andtellers were given a percentage commission for each sale, districtmanagers were required to hit specific sales numbers to earn bonuses,and cross-selling success was factored into top executives’ annualbonuses.25


Metrics tracking was strict and unforgiving. Branch personnelwere assigned ambitious sales numbers and their progress was trackedclosely in a daily “Motivator Report.”26 Each branch was requiredto report daily sales four times per day: at 11 a.m., 1 p.m., 3 p.m.,and 5 p.m.27 One area president told employees to “do whatever ittakes” to sell.28 At some branches, employees reportedly could notleave until they reached their daily sales goal.29

Bank personnel who did not meet sales goals were coached toincrease their numbers, including “objection-handling” training tocoerce people into buying more products. If they could still not hittheir numbers, they were terminated from the company. Managerswho did not do well enough were publicly criticized or fired.30

Beginning in 2013, reports began to surface that Wells Fargoemployees had engaged in, and were still currently engaging in,questionable practices to hit their sales numbers. A former employeereported that members of his Los Angeles branch opened accounts orcredit cards for customers without their consent, saying a computerglitch had occurred if customers complained. He also reported thatemployees lied to customers-saying that certain products could onlybe purchased together-to hit their numbers.31 Other tactics to meetsales goals included encouraging customers to open unnecessarymultiple checking accounts – one for groceries, one for travel, onefor emergencies, and so on32 – and creating fake email addressees toenroll customers in online banking.33

Before the scandal went public, Wells Fargo made a number ofchanges that seemed to try to address its problems. The companyfired over 5300 employees for ethics violations between 2011 and2016,34 rolled out a “Quality of Sale” Report Card that set limitson the terms of a sale,35 expanded ethics training, and explicitly toldemployees not to create fake accounts.36 There was, however, oneglaring omission: no changes were made to “Going for Gr-Eight.”Just as VW engineers were unable to design a clean diesel enginein ways that were “permissible,” Wells Fargo employees were unableto meet sales goals without engaging in shady practices. There wassimply a limit to how many products any one customer’s wallet could


allow. As one former banker put it, “They [the higher ups] warnedus about this [unethical] type of behavior . . . but the reality was thatpeople had to meet their goals. They needed a paycheck.”37

Eventually, federal and state regulators opened an investigationinto the bank’s practices. Their report found that from 2011 to 2016,employees in the Community Banking division, in order to boostsales figures, opened two million unauthorized customer accountsand credit cards and sold products and services to customers underfalse pretenses.38 The investigation also found that several employeeswho witnessed the unethical behavior had reported it to their super-visors or to the ethics hotline. One even claimed to have emailedStumpf about it. Some employees were later terminated for blowingthe whistle.39

Like Volkswagen, Wells Fargo’s avoidable failure was not theresult of one bad apple but of a system that demanded hitting targetsso ambitious they could only be met by deceit. Employees operatedin a culture of fear that brooked no dissent. Rather than manifestinginterest in salespeople’s experiences while executing the cross-sellingstrategy and using what was being learned in the field to shift orsharpen the company’s strategy,40 managers sent a clear message:produce – or else.

Fearing the Truth

A similar script to that of VW and Wells Fargo was followed yearsearlier – across the ocean and in another industry. Nokia, whichtraces its origins as a company to an 1865 paper mill in the townof Nokia, Finland,41 had become, by the 1980s, a pioneering tele-com company in the world’s burgeoning cellular networks. Led byCEO Kari Kairamo, by the late 1990s Nokia was the world’s leadingmobile phone manufacturer, with a 23% market share.42 By the early2000s, as a developer of the Symbian operating system, the companyseemed well poised to ride what would become the smartphone’sexponential rise.


Instead, Nokia became another casualty of avoidable failure. ByJune 2011, the company’s share of the smartphone market had fallenfar, and by 2012, its market value had dropped by over 75%.43 Thecompany had lost its innovative edge, its lead as a handset manufac-turer, and over two billion euros. In September 2013, the company,conceding defeat, announced the sale of its Device and Services busi-ness to Microsoft.44

Although it was not a tangled web of deceit that destroyed Nokia,as at Volkswagen and Wells Fargo, all three companies were handi-capped by a culture of fear. For instance, an in-depth investigation ofNokia’s rise and fall in the smartphone industry between 2005 and2010, which included interviews with 76 managers and engineers atNokia, concluded that the company lost the smartphone battle not asa result of poor vision or a few bad managers but at least partly dueto a “fearful emotional climate” that created company-wide inertia,especially in response to threats from powerful competitors.45 Suchfear, said the study’s authors, was “grounded in a culture of tempera-mental leaders and frightened middle managers, scared of telling thetruth.”46

The truth was that beginning in the first decades of thetwenty-first century, the mobile phone industry had become increas-ingly competitive. Having staked its claim on the featurephone,Nokia was unwilling or unable to recognize the potential of thecomplex and expensive-to-develop software platform that becametoday’s smartphone. In contrast Apple and Google, following theCanadian company RIM’s introduction of the Blackberry, spentbillions developing the proprietary platforms IOS and Android, bothof which overshadowed Nokia’s Symbian platform and effectivelylaunched the smartphone revolution. In other words, Nokia founditself in a rapidly changing, knowledge-intensive industry, where col-laboration, innovation, and communication were quickly becomingvital to future success.

Lacking a psychologically safe climate where candor wasexpected, Nokia’s top managers and middle managers engaged in asubtle dance of mutual fear. When middle managers asked critical


questions about the company’s direction, they were told to “focuson implementation.”47 People who could not comply with topmanagers’ unreasonable requests were “labeled a loser” or “puttheir reputations on the line.”48 One executive president was said tohave “pounded the table so hard that pieces of fruit went flying.”49

Olli-Pekka Kallasvuo, former chairman and CEO of Nokia, wasdescribed as “extremely temperamental.”50 Managers reported thatthey regularly saw him “shouting at people at the top of his lungs”and “it was very difficult to tell him things he didn’t want to hear.”51

For their part, executives, fearful of the external market threats thecompany was facing, particularly from software developers at Appleand Google, did not communicate the severity of those threats to mid-dle managers. One top manager, confessing to the fear that higher upsfelt and the way that influenced management practice, said, “it wasclear that we feared the iPhone. So we told the middle managers thatthey had to deliver touch-phones quickly.”52 Middle managers, afraidto deliver bad news, led their superiors to develop an overly optimisticperception of Nokia’s technological capabilities in featurephones andto neglect long-term investments in developing more complex inno-vation. As one manager put it, “In Nokia’s R&D, the culture wassuch that they wanted to please the upper levels. They wanted to givethem good news . . . not a reality check.”53

A reality check would have required that managers (both the tem-peramental and the frightened) put aside their fears and speak candidlyto one another. Yet such candor seemed impossible, and the win-dow for innovation and redirection passed. In 2007, as the industrybecame ever more software-reliant, the Finnish telecom companysank still lower. More and more mobile phone companies turnedto Google’s open source Android operating system. By 2008, whenApple launched the iPhone 3G and the App Store, it was too late tocatch up. Although Nokia continued to develop software and launchnew products, it would underperform and undersell compared to itsmore agile competitors.

Clearly, it is not possible to say that psychological safety wouldhave ensured Nokia’s success in an increasingly competitive industry.


Success required constant innovation, fueled by expertise, ingenuity,and teamwork. But without psychological safety, it is difficult forexpertise and ingenuity to be put to good use. And with Nokia’ssenior executives in the dark about where the company and its tech-nology really stood, the company simply could not learn fast enoughto survive. A decade later, Nokia was able to make a comeback. Asyou will learn in Chapter 7, members of senior management wouldlater realize that they had to change how they spoke and interactedto develop a better strategy.

Who Regulates the Regulators?

In the Nokia, Wells Fargo, and VW cases, we saw the perniciouseffects of a culture of fear inside companies with ambitious dreams.What about when one company provides services to, or reviews theactivities of, another? When relationships between companies are ham-pered by a culture of fear, the risks intensify, both for the organizationsand for society.

Following the 2008–2009 global financial crisis, the FederalReserve Bank of New York (FRBNY) received ample condemnationand criticism from the American public and Congress for its failureto effectively regulate the excessive financial risk-taking of several ofthe big US banks.54 In response, the FRBNY commissioned a reportto study itself. Bill Dudley, President of FRBNY, asked ColumbiaBusiness School Professor David Beim to investigate and assess theFRBNY’s “organization and practices, with a particular focus onBank Supervision.”55 The intention was to reveal lessons learnedthat could be used to improve the Feds’ ability to supervise banksand monitor systemic risk going forward.

Beim and a small team interviewed approximately two dozenpeople who worked at the FRBNY, mostly senior officers, aboutthings the Fed did well and didn’t do well leading up to the crisis.The result of the examination was the 2009 Report of Systemic Riskand Bank Supervision. The report allocated considerable attention tothe FRBNY’s culture and communication. In it, Beim described a


workplace suffused with low psychological safety in which regula-tory officers tasked with monitoring individual banks like GoldmanSachs felt “intimidated and passive,” and thus were not “effective incommunicating with other areas, forming their own views and sig-naling when something important seems to be wrong.” As a result,the regulators “just followed orders.”56

As part of their jobs, regulatory supervisors were involved in dis-cussions about individual bank processes and policies, often focusingon specific and large-scale transactions a bank had made or was con-sidering making. Every large bank was assigned a FRBNY regulatoryteam, tasked with the job of deciding whether a particular transactionwas kosher. Here, Beim found that real decision-making was stymiedby groupthink or “striving for consensus” – issues were discussed atlength without moving to constructive action. The discussions werenotably devoid of frank debate and cooperation, where people spokeup about problems and offered solutions, as warranted in any orga-nization where highly complex processes are constantly unfoldingat a furious pace. The report emphasized fear of speaking up as afrequent theme that characterized FRBNY meetings and employeeexperiences in all aspects of their job. It presented stark quotes frominterviewees, such as “grow up in this culture and you’ll find thatsmall mistakes are not tolerated,” and “[you] don’t want to be too faroutside where management is thinking.”57

The relationship between the regulators and the bank managerswas singled out as especially fraught. For one, an information asym-metry existed between the two groups that put the regulators at adisadvantage. Because the regulators had to request information fromthe banks, the banks could act as gatekeepers, in turn making theregulators feel dependent on the bank’s willingness and good gracefor timely and useful information. This led, as Beim argued, reg-ulators to adopt a nonconfrontational and often overly deferentialstyle to smooth their attempts to obtain information.58 Most criti-cally, Beim reported that within three weeks of his investigation hesaw signs of regulatory capture, a phenomenon that journalist Ira Glasslater described as like “a watchdog who licks the face of an intruderand plays catch with the intruder instead of barking at him.”59 The


regulators were, in a sense, disabled from effectively carrying out theirregulatory duties by a culture of fear and deference.

What makes this dynamic especially frustrating is that the bankswere required by law to hand over whatever information the Fedsasked for. Carmen Segarra, who worked as a regulator after the Beiminvestigation, said, “The Fed has both the power to get the informa-tion and the power to punish a bank if it chooses to withhold it.”When asked why she thought the regulators chose deference eventhough they possessed this power, her answer was succinct: “they arecoming from a place of fear.”60

Could the colossal collapse of a financial system the likes of whichthe world had not seen since the 1930s have been prevented hadthe banks and regulators worked in a climate of psychological safety?That may be a stretch. Lax regulations, greed, and faulty incentiveswere certainly important contributing factors. However, we can saythat the culture of fear silenced or inhibited anyone who wanted toask questions or criticize, thereby squandering many opportunities tocatch and correct excessive risk-taking and other sources of economicfailure.

Avoiding Avoidable Failure

Volkswagen, Wells Fargo, Nokia, and the New York Federal Reserveserve as vivid examples of organizations that boasted deep reservoirsof expertise, driven, intelligent leaders, and clearly articulated goals.None lacked capable employees in any of the relevant fields requiredfor the organization to succeed in its industry. In short, they had thetalent. What they lacked was the leadership needed to ensure thata climate of psychological safety permeated the workplace, allowingpeople to speak truth to power inside the company – and, in the caseof the Fed, to their industry partners. Chapter 7 will focus on whatleaders need to do to create and recover psychological safety; here,I simply note that the kinds of large-scale business failures describedin this chapter are preventable.


None of these failures occurred overnight or out of the blue.Quite the opposite. The seeds of failure were taking root for monthsor years while senior management remained blissfully unaware. Inmany organizations, like those discussed in this chapter, countlesssmall problems routinely occur, presenting early warning signs thatthe company’s strategy may be falling short and needs to be revisited.Yet these signals are often squandered. Preventing avoidable failurethus starts with encouraging people throughout a company to pushback, share data, and actively report on what is really happening inthe lab or in the market so as to create a continuous loop of learningand agile execution.

Each of the stories in this chapter can be seen as a case of strategicfailure. What started as small gaps in execution spiraled into dramatic,headline-making failures when new information created by actualexperience – whether of engineers or salespeople – was not capturedand put to good use in rethinking and redirecting company efforts.61

For instance, Wells Fargo’s cross-selling strategy bumped up againstcustomers’ real spending power, planting a seed of strategic failure.But what cemented the failure was the salespeople’s belief that seniormanagers would not tolerate underperformance. That they found iteasier to fabricate false accounts than to report what they were learn-ing in the field is as powerful a signal of low psychological safety asyou can find.

In focusing our attention on psychological safety, I do not meanto dismiss the ethical dimensions of any of these cases. Wells Fargo,for instance. Yet to view the customer-accounts fraud as the result ofindividually-corrupt salespeople does not square with the widespreadnature of the behavior in the company, which points to a system setup to fail. Set up to fail by the pernicious combination of a top-downstrategy and insufficient psychological safety to encourage sharing badnews up the hierarchy. A similar point can be made about the VWand Fed cases. As argued earlier in this chapter, any explanation thatlooks only for a corrupt or foolish individual or individuals will beincomplete, given the complex dynamics at play. What is interestingto consider, however, is the extent to which having information about


shortcomings come to light earlier rather than later can nearly alwaysmitigate the size and impact of failures and sometimes prevent themaltogether.

Adopting an Agile Approach to Strategy

Taken together, these four cases suggest the necessity of adoptingalternate perspectives on strategy that are more in tune with thenature of value creation in today’s VUCA world. Solvay BusinessSchool Professor Paul Verdin and I developed a perspective thatframes an organization’s strategy as a hypothesis rather than a plan.62

Like all hypotheses, it starts with situation assessment and analysis –strategy’s classic tools. Also, like all hypotheses, it must be testedthrough action. When strategy is seen as a hypothesis to be con-tinually tested, encounters with customers provide valuable dataof ongoing interest to senior executives. Imagine if Wells Fargohad adopted an agile approach to strategy: the company’s topmanagement would then have taken repeated instances of missedtargets or false accounts as useful data to help it assess the efficacyof the original cross-selling strategy. This learning would then havetriggered much-needed strategic adaptation.

Of course, sometimes, poor performance is simply poor perfor-mance. People underperforming. Not trying hard enough. Some-times, companies do in fact need to find ways to better motivate andmanage employees to help them reach desired performance standards.However, in a VUCA world, this is not the only explanation formissing a desired target; it is not even the most likely explanation.Early signs of gaps between results and plans must be viewed first asdata – triggering analysis – before concluding that the gaps are clearand obvious evidence of employee underperformance.

Cheating and covering up are natural by-products of a top-downculture that does not accept “no” or “it can’t be done” for an answer.But combining this culture with a belief that a brilliant strategy for-mulated in the past will hold indefinitely into the future becomes a


certain recipe for failure. At both VW and Wells Fargo, signs thatcorners were being cut were repeatedly ignored. Thus, the illusionthat the top-down strategies were working persisted – for a while.Particularly poignant is that disconfirming data were available for asurprisingly long time, but they were not put to good use.

Success in a VUCA world requires senior executives to engagethoughtfully and frequently with company operations across all levelsand departments. The people on the front line who create and deliverproducts and services are privy to the most important strategic datathe company has available. They know what customers want, whatcompetitors are doing, and what the latest technology allows. Orga-nizational learning – championed by company leaders but enactedby everyone – requires actively seeking deviations that challenge theassumptions underpinning a current strategy. Then, of course, thesedeviations must be welcomed because of their informative value foradapting the original strategy. Ironically, pushing harder on “exe-cution” in response to early signals of underperformance may onlyaggravate the problem if shortcomings reveal that prior market intel-ligence or assumptions about the business model were flawed.

Finally, as unfortunate as the business failures in this chapter mayhave been, in many ways they pale in comparison to the human costsof low psychological safety explored in Chapter 4. Here we will seethe even more vital role of speaking up to avoid preventable harm.

Chapter 3 Takeaways

◾ Leaders who welcome only good news create fear that blocksthem from hearing the truth.

◾ Many managers confuse setting high standards with good man-agement.

◾ A lack of psychological safety can create an illusion of successthat eventually turns into serious business failures.

◾ Early information about shortcomings can nearly always miti-gate the size and impact of future, large-scale failure.


Endnotes

1. Vlasic, B. “Volkswagen Official Gets 7-Year Term in Diesel-EmissionsCheating.” The New York Times. December 6, 2017. https://www.nytimes.com/2017/12/06/business/oliver-schmidt-volkswagen.htmlAccessed June 13, 2018.

2. Kwak, J. “How Not to Regulate.” The Atlantic. September 30, 2014.https://www.theatlantic.com/business/archive/2014/09/how-not-to-regulate/380919/ Accessed June 13, 2018.

3. The Volkswagen story in this chapter draws from new sources citedindividually and from the following academic case studies:◾ Giolito, V., Verdin, P., Hamwi, M., & Oualadj, Y. Volkswagen: A

Global Champion in the Making? Case Study. Solvay Brussels SchoolEconomics & Management, 2017; Lynch, L.J., Cutro, C., & Bird, E.

◾ The Volkswagen Emissions Scandal. Case Study. UVA No. 7245.Charlottesville, VA. University of Virginia, Darden Business Pub-lishing, 2016; and

◾ Schuetz, M. Dieselgate – Heavy Fumes Exhausting the VolkswagenGroup. Case Study. HK No. 1089. Hong Kong. The University ofHong Kong Asia Case Research Center, 2016.

4. Ewing, J. “Volkswagen C.E.O. Martin Winterkorn Resigns AmidEmissions Scandal.” The New York Times. September 23, 2015.https://www.nytimes.com/2015/09/24/business/international/volkswagen-chief-martin-winterkorn-resigns-amid-emissions-scandal.html Accessed June 13, 2018.

5. Parloff, R. “How VW Paid $25 Billion for ‘Dieselgate’ – and Got OffEasy.” Fortune Magazine. February 6, 2018. http://fortune.com/2018/02/06/volkswagen-vw-emissions-scandal-penalties/ Accessed June 13,2018.

6. Ibid.7. Sorokanich, B. “Report: Bosch Warned VW About Diesel Emissions

Cheating in 2007.” Car and Driver. September 28, 2015. https://blog.caranddriver.com/report-bosch-warned-vw-about-diesel-emissions-cheating-in-2007/ Accessed June 13, 2018.

8. Hakim, D., Kessler A.M., & Ewing, J. “As Volkswagen Pushed to BeNo. 1, Ambitions Fueled a Scandal.” The New York Times, Septem-ber 26, 2015. https://www.nytimes.com/2015/09/27/business/as-vw-pushed-to-be-no-1-ambitions-fueled-a-scandal.html Accessed June 13,2018.

https://www.nytimes.com/2017/12/06/business/oliver-schmidt-volkswagen.html

https://www.nytimes.com/2017/12/06/business/oliver-schmidt-volkswagen.html

https://www.theatlantic.com/business/archive/2014/09/how-not-to-regulate/380919

https://www.theatlantic.com/business/archive/2014/09/how-not-to-regulate/380919

https://www.nytimes.com/2015/09/24/business/international/volkswagen-chief-martin-winterkorn-resigns-amid-emissions-scandal.html



http://fortune.com/2018/02/06/volkswagen-vw-emissions-scandal-penalties

http://fortune.com/2018/02/06/volkswagen-vw-emissions-scandal-penalties

https://blog.caranddriver.com/report-bosch-warned-vw-about-diesel-emissions-cheating-in-2007



https://www.nytimes.com/2015/09/27/business/as-vw-pushed-to-be-no-1-ambitions-fueled-a-scandal.html





9. Ewing, J. 2015, op cit.10. Cremer, A. & Bergin, T. “Fear and Respect: VW’s culture under Win-

terkorn.” Reuters. October 10, 2015. https://www.reuters.com/article/us-volkswagen-emissions-culture/fear-and-respect-vws-culture-under-winterkorn-idUSKCN0S40MT20151010 Accessed June 13, 2018.

11. https://www.youtube.com/watch?v=YpPNVSQmR5c12. Lutz, B. “One Man Established the Culture that Led to VW’s

Emission Scandal.” Road and Track. November 4, 2015. https://www.roadandtrack.com/car-culture/a27197/bob-lutz-vw-diesel-fiasco/Accessed June 13, 2018.

13. Ibid.14. Kiley, D. Getting the Bugs Out: The Rise, Fall, and Comeback of Volkswagen

in America. John Wiley & Sons, 2002. 38–49. Print.15. https://www.youtube.com/watch?v=DfGs2Y5WJ14.16. Cremer, A. & Bergin, T, 2015, op cit.17. Ibid.18. Ibid.19. Ibid.20. Details on the Wells Fargo story come from Lynch, L.J., Coleman, A.R.,

& Cutro, C. The Wells Fargo Banking Scandal. Case Study. UVA No.7267. Charlottesville, VA. University of Virginia, Darden Business Pub-lishing, 2017.

21. Wells Fargo, 2015 annual report22. Wells Fargo, 2010 annual report23. Wells Fargo, 2015 annual report24. Gonzales, R. “Wells Fargo CEO John Stumpf Resigns Amid Scandal.”

NPR, October 12, 2016. https://www.npr.org/sections/thetwo-way/2016/10/12/497729371/wells-fargo-ceo-john-stumpf-resigns-amid-scandal Accessed June 13, 2018.

25. Reckard, E.S. “Wells Fargo’s Pressure-Cooker Sales Culture Comesat a Cost.” The Los Angeles Times, December 21, 2013. http://www.latimes.com/business/la-fi-wells-fargo-sale-pressure-20131222-story.html Accessed June 13, 2018.

26. Keller, L.J., Campbell, D., & Mehrotra, K. “While 5,000 Wells FargoEmployees Got Fired, Their Bosses Thrived.” Bloomberg. November3, 2016. https://www.bloomberg.com/news/articles/2016-11-03/wells-fargo-s-stars-climbed-while-abuses-flourished-beneath-themAccessed June 13, 2018.

27. Cao, A. “Lawsuit Alleges Exactly How Wells Fargo Pushed Employeesto Abuse Customers.” TIME. September 29, 2016. http://time.com/

https://www.reuters.com/article/us-volkswagen-emissions-culture/fear-and-respect-vws-culture-under-winterkorn-idUSKCN0S40MT20151010

https://www.youtube.com/watch?v=YpPNVSQmR5c

https://www.roadandtrack.com/car-culture/a27197/bob-lutz-vw-diesel-fiasco

https://www.roadandtrack.com/car-culture/a27197/bob-lutz-vw-diesel-fiasco

https://www.youtube.com/watch?v=DfGs2Y5WJ14

https://www.npr.org/sections/thetwo-way/2016/10/12/497729371/wells-fargo-ceo-john-stumpf-resigns-amid-scandal



http://www.latimes.com/business/la-fi-wells-fargo-sale-pressure-20131222-story.html



https://www.bloomberg.com/news/articles/2016-11-03/wells-fargo-s-stars-climbed-while-abuses-flourished-beneath-them

https://www.bloomberg.com/news/articles/2016-11-03/wells-fargo-s-stars-climbed-while-abuses-flourished-beneath-them

http://time.com/money/4510482/wells-fargo-fake-accounts-class-action-lawsuit




money/4510482/wells-fargo-fake-accounts-class-action-lawsuit/Accessed June 13, 2018.

28. Mehrotra, K. “Wells Fargo Ex-Managers’ Suit Puts Scandal BlameHigher Up Chain.” Bloomberg. December 8, 2016. https://www.bloomberg.com/news/articles/2016-12-08/wells-fargo-ex-managers-suit-puts-scandal-blame-higher-up-chain Accessed June 13, 2018.

29. Reckard, E.S. December 21, 2013, op cit.30. Cowley, S. “Voices From Wells Fargo: ‘I Thought I Was Having a

Heart Attack.’” The New York Times. October 20, 2016. https://www.nytimes.com/2016/10/21/business/dealbook/voices-from-wells-fargo-i-thought-i-was-having-a-heart-attack.html Accessed June 13,2018.

31. Cao, A. September 29, 2016, op cit.32. Cowley, S. October 20, 2016, op cit.33. Glazer, E. & Rexrode, C. “Wells Fargo CEO Defends Bank Culture,

Lays Blame With Bad Employees.” The Wall Street Journal. September13, 2016. https://www.wsj.com/articles/wells-fargo-ceo-defends-bank-culture-lays-blame-with-bad-employees-1473784452 AccessedJune 13, 2018.

34. Egan, M. September 8, 2016, op cit.35. Freed, D. & Reckhard, E.S. “Wells Fargo Faces Costly Overhaul of

Bankrupt Sales Culture.” Reuters, October 12, 2016.36. Corkery, M. & Cowley, S. “Wells Fargo Warned Workers Against

Sham Accounts, but ‘They Needed a Paycheck.’” The New YorkTimes, September 16, 2016. https://www.nytimes.com/2016/09/17/business/dealbook/wells-fargo-warned-workers-against-fake-accounts-but-they-needed-a-paycheck.html Accessed June 13, 2018.

37. Ibid.38. Consumer Financial Protection Bureau press release. “Consumer

Financial Protection Bureau Fines Wells Fargo $100 Million forWidespread Illegal Practice of Secretly Opening UnauthorizedAccounts.” ConsumerFinance.gov, September 8, 2016. https://www.consumerfinance.gov/about-us/newsroom/consumer-financial-protection-bureau-fines-wells-fargo-100-million-widespread-illegal-practice-secretly-opening-unauthorized-accounts/ Accessed June 13,2018.

39. Egan, M. “Wells Fargo Admits to Signs of Worker Retaliation.”CNN Money. January 23, 2017. http://money.cnn.com/2017/01/23/investing/wells-fargo-retaliation-ethics-line/index.html Accessed June13, 2018.

http://time.com/money/4510482/wells-fargo-fake-accounts-class-action-lawsuit

https://www.bloomberg.com/news/articles/2016-12-08/wells-fargo-ex-managers-suit-puts-scandal-blame-higher-up-chain

https://www.nytimes.com/2016/10/21/business/dealbook/voices-from-wells-fargo-i-thought-i-was-having-a-heart-attack.html



https://www.wsj.com/articles/wells-fargo-ceo-defends-bank-culture-lays-blame-with-bad-employees-1473784452

https://www.wsj.com/articles/wells-fargo-ceo-defends-bank-culture-lays-blame-with-bad-employees-1473784452

https://www.nytimes.com/2016/09/17/business/dealbook/wells-fargo-warned-workers-against-fake-accounts-but-they-needed-a-paycheck.html



http://consumerfinance.gov

https://www.consumerfinance.gov/about-us/newsroom/consumer-financial-protection-bureau-fines-wells-fargo-100-million-widespread-illegal-practice-secretly-opening-unauthorized-accounts




http://money.cnn.com/2017/01/23/investing/wells-fargo-retaliation-ethics-line/index.html

http://money.cnn.com/2017/01/23/investing/wells-fargo-retaliation-ethics-line/index.html




40. Edmondson, A.C. & Verdin, P.J. “Your Strategy Should Be a HypothesisYou Constantly Adjust.” Harvard Business Review. November 9, 2017.https://hbr.org/2017/11/your-strategy-should-be-a-hypothesis-you-constantly-adjust Accessed June 13, 2018.

41. “Our History.” Nokia. https://www.nokia.com/en_int/about-us/who-we-are/our-history Accessed June 7, 2018.

42. Nokia Corporation, 1998 annual report.43. Huy, Q. & Vuori, T. “Who Killed Nokia? Nokia Did.” INSEAD

Knowledge. September 22, 2015. https://knowledge.insead.edu/strategy/who-killed-nokia-nokia-did-4268 Accessed June 13, 2018.

44. Bass, D., Heiskanen, V., & Fickling, D. “Microsoft to Buy Nokia’sDevices Unit for $7.2 Billion.” Bloomberg. September 3, 2013. https://www.bloomberg.com/news/articles/2013-09-03/microsoft-to-buy-nokia-s-devices-business-for-5-44-billion-euros Accessed June 13,2018.

45. Huy, Q. & Vuori, T. September 22, 2015, op cit.46. Ibid.47. Vuori, T. & Huy, Q. “Distributed Attention and Shared Emotions in the

Innovation Process: How Nokia Lost the Smartphone Battle.” Admin-istrative Science Quarterly 61.1 (2016): 23.

48. Ibid.49. Ibid.50. Ibid.51. Ibid.52. Vuori, T. & Huy, Q. (2016): 30.53. Vuori, T. & Huy, Q. (2016): 32.54. Protess, B. & Craig, S. “Harsh Words for Regulators in Crisis

Commission Report.” The New York Times. January 27, 2011.https://dealbook.nytimes.com/2011/01/27/harsh-words-for-regulators-in-crisis-commission-report/?mtrref=www.google.com&gwh=54322022775D2A4C1766CE843F23C604&gwt=pay AccessedJune 13, 2018.

55. Beim, D. & McCurdy, C. “Report on Systemic Risk and BankSupervision” Federal Reserve Bank of New York Report. 2009. 1. https://info.publicintelligence.net/FRBNY-BankSupervisionReport.pdf .Accessed June 1, 2018.

56. Beim, D. & McCurdy, C. 2009: 9.57. Ibid.58. Beim, D. & McCurdy, C. 2009: 19.

https://hbr.org/2017/11/your-strategy-should-be-a-hypothesis-you-constantly-adjust

https://hbr.org/2017/11/your-strategy-should-be-a-hypothesis-you-constantly-adjust

https://www.nokia.com/en_int/about-us/who-we-are/our-history

https://www.nokia.com/en_int/about-us/who-we-are/our-history

https://knowledge.insead.edu/strategy/who-killed-nokia-nokia-did-4268

https://knowledge.insead.edu/strategy/who-killed-nokia-nokia-did-4268

https://www.bloomberg.com/news/articles/2013-09-03/microsoft-to-buy-nokia-s-devices-business-for-5-44-billion-euros



https://dealbook.nytimes.com/2011/01/27/harsh-words-for-regulators-in-crisis-commission-report/?mtrref=www.google.com&gwh=54322022775D2A4C1766CE843F23C604&gwt=pay



https://info.publicintelligence.net/FRBNY-BankSupervisionReport.pdf

https://info.publicintelligence.net/FRBNY-BankSupervisionReport.pdf


59. “The Secret Recordings of Carmen Segarra.” This American Life.September 26, 2014. https://www.thisamericanlife.org/536/the-secret-recordings-of-carmen-segarra. Accessed June 1, 2018.

60. Ibid.61. Edmondson, A.C. & Verdin, P.J. “The strategic imperative of psycho-

logical safety and organizational error management.” How could this hap-pen? Managing errors in organizations. Ed. J. Hagen. Palgrave/MacMillan:in press.

62. Edmondson, A.C. & Verdin, P.J. November 9, 2017, op cit.

https://www.thisamericanlife.org/536/the-secret-recordings-of-carmen-segarra

https://www.thisamericanlife.org/536/the-secret-recordings-of-carmen-segarra

4Dangerous Silence

“Regret for the things we did can be tempered by time; it is regret for the things wedid not do that is inconsolable.”

—Sydney Harris1

More than just business failure is at stake when psychological safetyis low. In many workplaces, people see something physically unsafeor wrong and fear reporting it. Or they feel bullied and intimidatedby someone but don’t mention it to supervisors or counselors. Thisreticence unfortunately can lead to widespread frustration, anxiety,depression, and even physical harm. In short, we live and work incommunities, cultures, and organizations in which not speaking upcan be hazardous to human health.

This chapter explores how silence at work leads to harm thatcould have been prevented. You will read stories that come predom-inantly, but not exclusively, from high-risk industries. In these cases,employees find themselves unable to speak up; the ensuing silencethen creates conditions for physical and emotional harm. Although

77


never easy, in some workplaces, as we will see in Chapter 5 andChapter 6, people do feel both safe and compelled to speak up. Thisgives everyone the chance to develop constructive solutions and avoidharmful outcomes.

We’ll start with stories of silence that gave rise to major accidentsin high-risk settings where risk and routine often exist in an uneasybalance. The first two accidents take place in the air. From there, we’llmove to a hospital bed, tsunami waves, and finally the volatile settingof public opinion.

Failing to Speak Up

On February 1, 2003, NASA’s Space Shuttle Columbia experienced acatastrophic reentry into the Earth’s atmosphere.2 All seven astronautsperished. Although space travel is obviously risky and fatal accidentsseem part of the territory, this particular accident did not come “outof the blue.” Two weeks earlier, a NASA engineer named RodneyRocha had watched launch-day video footage, a day after what hadseemed to be a picture-perfect launch on a sunny Florida morning.But something seemed amiss. Rocha played the tape over and over.He thought a chunk of insulating foam might have fallen off the shut-tle’s external tank and struck the left wing of the craft. The videoimages were grainy, shot from a great distance, and it was impossi-ble to really tell whether or not the foam had caused damage, butRocha could not help worrying about the size and position of thatgrainy moving dot he saw on the screen. To resolve the ambiguity,Rocha wanted to get satellite photos of the Shuttle’s wing. But thiswould require NASA higher ups to ask the Department of Defensefor help.

Rocha emailed his boss to see if he could get help authorizing arequest for satellite images. His boss thought it unnecessary and saidso. Discouraged, Rocha sent an emotional email to his fellow engi-neers, later explaining that “engineers were . . . not to send messagesmuch higher than their own rung in the ladder.”3 Working with an

Dangerous Silence 79

ad hoc team of engineers to assess the damage, he was unable to resolvehis concern about possible damage without obtaining images. A weeklater, when the foam strike possibility was briefly discussed by seniormanagers in the formal mission management team meeting, Rocha,sitting on the periphery, observed silently.

A formal investigation by experts would later conclude that alarge hole in the shuttle wing occurred when a briefcase-sized pieceof foam hit the leading edge of the wing, causing the accident.4

They also identified two, albeit difficult and highly-uncertain, res-cue options that might have prevented the tragic deaths. Reportingon the investigation, ABC News anchor Charlie Gibson asked Rochawhy he hadn’t spoken up in the meeting. The engineer replied, “Ijust couldn’t do it. I’m too low down [in the organization] . . . andshe [meaning Mission Management Team Leader Linda Ham] is wayup here,” gesturing with his hand held above his head.5

Rocha’s statement captures a subtle but crucial aspect of the psy-chology of speaking up at work. Consider his words carefully. He didnot say, “I chose not to speak,” or “I felt it was not right to speak.” Hesaid that he “couldn’t” speak. Oddly, this description is apt. The psy-chological experience of having something to say yet feeling literallyunable to do so is painfully real for many employees and very com-mon in organizational hierarchies, like that of NASA in 2003. Wecan all recognize this phenomenon. We understand why his handsspontaneously depicted that poignant vertical ladder. When probed,as Rocha was by Gibson, many people report a similar experienceof feeling unable to speak up when hierarchy is made salient. Mean-while, the higher ups in a position to listen and learn are often blindto the silencing effects of their presence.

What Was Not Said

Twenty-six years earlier, workplace silence played a major role inthe collision of two Boeing 747 jets on an island runway in theCanary Islands in March 1977.6 The crash ignited two jumbo jets


into flames, and 583 people died. Subsequent investigations into whathas been called the Tenerife disaster, still considered the worst acci-dent in the history of civil aviation, were among the first to studythe roles played by human factors in airline fatalities. The result-ing changes made to aviation procedures and cockpit training laidthe groundwork for some of today’s most crucial psychological safetymeasures.

Let’s look at what went wrong on that afternoon in late Marchat the small Los Rodeos Airport on the island of Tenerife. The run-way was covered in heavy fog and the airport was small, which madeit difficult for the pilots of both aircrafts to see the runway and oneanother. An unexpected landing at Tenerife due to a bomb scare ear-lier that day at nearby Las Palamas airport put extra stress on the crew,intent on keeping to their scheduled flight arrival times. Air controlpersonnel may have been watching a sports game, distracting theirattention. However, these relatively common, if unfavorable, condi-tions need not have resulted in tragedy. If we look more closely intowhat was said in the aircraft cockpit – and more importantly, whatwas not said, and why not – we can better understand the outsized roleplayed by psychological safety.

Captain Jacob Veldhuyzen van Zanten, one of the company’s mostsenior pilots, chief flight trainer of most of the company’s 747 pilots,and head of flight safety for Royal Dutch Airlines (KLM), piloted theflight.7 Nicknamed “Mr. KLM,” van Zanten held the power to issuepilots’ licenses and oversaw pilots’ six-month flight checks to deter-mine whether licenses would be extended. His photograph, whichhad just appeared in a KLM advertising spread, depicted a smilingand confident man in a white shirt sitting in front of a control panel.He looked like a man who was comfortable being in charge.

Flying with van Zanten that day were two other top-notch andhighly-experienced pilots: First Officer Klaas Meurs, age 32, andFlight Engineer Willem Schreuder, age 48. Importantly, two monthsearlier, van Zanten had been Meur’s “check pilot,” testing his abilityto fly the Boeing 747.


The crucial moments came as the KLM and the Pan Am flightswere preparing for takeoff. Immediately after lining up on therunway, Captain van Zanten impatiently advanced the throttles andthe aircraft started to move forward. First Officer Meurs, implyingthat van Zanten was moving too soon, then advised that air trafficcontrol (ATC) had not yet given them clearance.

Van Zanten, sounding irritated, responded: “No, I know that. Goahead, ask.”8

Following his captain’s request, Meurs then radioed the towerthat they were “ready for takeoff” and “waiting for our ATCclearance.” The ATC then specified the route that the aircraft wasto follow after takeoff. Although the ATC used the word “takeoff,”their communication did not include an explicit statement that KLMwas cleared for takeoff. Meurs began reading the flight clearance backto the controller, but van Zanten interrupted with an imperative:“We’re going.”

Given the captain’s authority, it was in this moment that Meursapparently did not feel safe enough to speak up. Meurs, in that splitsecond, did not open his mouth to say, “wait for clearance!”

Meanwhile, after the KLM plane had started its takeoff roll, thetower instructed the Pan Am crew to “report when runway clear.” Towhich the Pan Am crew replied, “OK, will report when we’re clear.”On hearing this, Flight Engineer Schreuder expressed his concernthat Pan Am was not clear of the runway by asking, “is he not clear,that Pan American?”

Van Zanten emphatically replied, “oh, yes,” and continued withthe takeoff.

And in this moment Schreuder did not say a thing. Althoughhe had correctly surmised that the Pan Am jet might be blockingtheir way, Schreuder did not challenge Van Zanten’s confident retort.He did not ask ATC to clarify or confirm by asking, for example,“is Pan American on the runway?” His reticence indicates a lackof the psychological safety that would make such a query all butsecond nature.


By then it was too late. The KLM Boeing was going too fast tostop when van Zanten, Meurs, and Schreuder finally could see thePan Am jet blocking their way. The KLM’s left-side engines, lowerfuselage, and main landing gear struck the upper right side of the PanAm’s fuselage, ripping apart the center. The KLM plane remainedbriefly airborne before going into a stall, rolling sharply, hitting theground, and igniting into a fireball.

Such is the inexorably psychological pull of hierarchy that evenwhen their own lives were at risk, not to mention the lives of oth-ers, the first officer and the flight engineer did not push back on theircaptain’s authority. In those moments where speaking up might makesense, we all go through an implicit decision-making process, weigh-ing the benefits and costs of speaking up. The problem, as explainedin Chapter 2, is that the benefits are often unclear and delayed (e.g.avoiding a possible collision) while the costs are tangible and imme-diate (van Zanten’s irritation and potential anger). As a result, weconsistently underweight the benefits and overweight the costs. Inthe case of Tenerife, this biased process led to disastrous outcomes.

Many who analyze events leading up to tragic accidents suchas this one-which could have been avoided had the junior officerspoken up-cannot help pointing out that people should demonstratea bit more backbone. Courage. It is impossible to disagree with thisassertion. Nonetheless, agreeing doesn’t make it effective. Exhortingpeople to speak up because it’s the right thing to do relies on an ethicalargument but is not a strategy for ensuring good outcomes. Insistingon acts of courage puts the onus on individuals without creating theconditions where the expectation is likely to be met.

For speaking up to become routine, psychological safety – andexpectations about speaking up – must become institutionalized andsystematized. After Tenerife, cockpit training was changed to placemore emphasis on crew decision-making, encourage pilots to asserttheir opinion when they believed something was wrong, and helpcaptains listen to concerns from co-pilots and crews.9 These measureswere a precursor to the official crew resource management (CRM)training that all pilots must now undergo.


Excessive Confidence in Authority

Medicine, like commercial aviation, is another profession whereauthority is well understood and tightly linked to one’s place in astrict hierarchy. A direct line of command, where everyone knowshis or her place, has its benefits. However, deference to others,especially in the face of ambiguity, can become the default mode ofoperation, leading everyone to believe that the person-on-top alwaysknows best. In some cases, an implicit belief that the person with thehighest place on the hierarchy must also be the authority can lead tofatal consequences. In other cases, an implicit belief in the authorityof the medical system itself can be fatal.

On December 3, 1994, Betsy Lehman, a 39-year-old motherof two and a healthcare columnist at The Boston Globe, died at theDana-Farber Cancer Institute while undergoing a third round ofhigh-dose chemotherapy for breast cancer.10 In part because of herprofession as a journalist, Lehman’s death was well publicized in themedia, especially once it was linked to a medical error.11

The Dana-Farber Cancer Institute where Lehman sought treat-ment was renowned for its cancer research and its success in treatingcomplex and difficult cases. With only 57 inpatient beds, its patientcare was a kind of boutique unit that enabled informal informationsharing among physicians, nurses, and pharmacy staff rather than theformal communications mechanisms that exist in a traditional hospitalsetting. As Senior Oncologist Stephen Sallan noted, “our confidencewas based on the assumption that if we were all wonderful then ourpharmacy safety would be wonderful.”12 Unfortunately, this assump-tion did not leave much room for questioning or routine checking.The absence of a Director of Nursing at the time of Lehman’s admit-tance, a post that had been vacant for over a year, also signals that themedical and clinical teams did not adequately appreciate the interde-pendence and complexity of their work.

Lehman was admitted to the Dana-Farber for the plannedchemotherapy on November 14, 1994. Although the chemother-apy agent was the commonly used cyclophosphamide, the dose


was especially high because Lehman’s treatment plan involveda cutting-edge stem-cell transplant. The protocol called for thechemotherapy to be infused over four days, with the amount givenduring each 24-hour period to be “barely shy of lethal.”13 As part ofthe clinical trial, Lehman was also given another drug, cimetidine,which was supposed to boost the effect of the first drug.14

In routine cancer treatments, courses of chemotherapy doses aretypically standardized; however, in a research trial such as Lehmanwas undergoing, upper limits could be ambiguous. At Dana-Farber,where 30% of patients might be enrolled in a clinical trial at anyone time, staff members who administered chemotherapy wereaccustomed to seeing unusual drug combinations and dosages.15

That may partly explain why no alarm bells went off even thoughthe prescription – written by a clinical research fellow in oncology,copied into Lehman’s records by a nurse, and filled by three differentpharmacists – had mistakenly ordered the entire four-day dosagefor each day, providing Lehman with four times the dosage she wassupposed to receive.

The treatment was expected to produce severe nausea and vom-iting. However, over the next three weeks in the hospital, Lehman’ssymptoms were extraordinary. She had not been as sick during thefirst two high-dose treatments. Now she was “grossly swollen” andhad abnormal blood and EKG tests.16 High-dose cyclophosphamidewas known to be toxic to the heart. Lehman’s husband reported thatshe was “vomiting sheets of tissue. [The doctors] said this was theworst they had ever seen. But the doctors said this was all normal withbone marrow transplant.”17 At one point, Lehman asked a nurse, “AmI going to die from vomiting?”18 Meanwhile, another patient, admit-ted shortly before Lehman, given the same incorrect chemother-apy dose, had suddenly collapsed and was rushed to the intensivecare unit.

The day before Lehman’s discharge, her symptoms seemed to beabating. And there were signs that the experimental stem cell trans-plant was proceeding successfully. An EKG, however, was abnormal.On December 3, the day of her discharge and the day she died of


heart failure, the last people she spoke to – a friend, a social worker,and a nurse – confirmed that she was very upset, frightened, and feltthat something “was wrong.”19 We do not know whether or not shehad voiced this concern as distinctly or coherently in the previousweeks. Surely, she must have wondered. Of course, an extremely illpatient is usually not in a position to assertively question her treatmentplan, especially one that is experimental.

The medical error was not discovered until three months later – bya routine data check rather than by a clinical inquiry. As part ofits corrective actions, Dana-Farber instituted automated medicationchecks into its chemotherapy procedures. Ultimately, Lehman’s deathbecame a catalyst for hospital and healthcare institutions in the US tocraft policy to help reduce medical errors, including more systemicchecking of routine procedures throughout a patient’s treatment pro-cess and more reporting provisions for caregivers, regardless of theirprofessional status.

From the perspective of psychological safety, however, the biggerquestion that remains is why, given Lehman’s extreme physical dis-tress, did no one deeply and persistently question whether somethinghad gone profoundly wrong? Did Lehman and her husband placetoo much trust in the highly regarded medical institution? Similarly,why did pharmacists not question the extraordinary fourfold dosageof the already high-dose chemotherapy agent? The same can be askedabout the nurses. Perhaps their implicit trust in the expertise of thephysician-researchers left them incurious. Or, they may have beenreluctant to speak up to inquire into rationale for the treatment planonly to be put down by their higher-status colleagues. We don’t knowwhether the nurses and physicians who observed Lehman’s symp-toms assigned too little significance to the type of side effects thehigh-dose chemotherapy was supposed to induce. No one involvedseemed to accurately assess the gravity of her condition. Ultimately,Betsy Lehman’s mother, Mildred K. Lehman, was the one who con-cisely summed up the problem: “Betsy’s life might have been savedif staff had stepped forward to attend to the multiple signs that hertreatment was far off course.”20


What is important to take away from this story, and what mosthospitals today work hard to avoid, is that a climate in which peopleerr on the side of silence – implicitly favoring self-protection andembarrassment avoidance over the possibility that one’s input maybe desperately needed in that moment – is a serious risk factor. Itis clearly far better for people to ask questions or raise concerns andbe wrong than it is for them to hold back, but most people don’tconsciously recognize that fact. Raising concerns that turn out to beunfounded presents a learning opportunity for the person speaking upand for those listening who thereby glean crucial information aboutwhat others understand or don’t understand about the situation orthe task.

A Culture of Silence

Cassandra, one of the most tragic characters in classical Greek mythol-ogy, was given the gift of prophecy along with the curse that shewould never be believed. Low levels of psychological safety can createa culture of silence. They can also create a Cassandra culture – an envi-ronment in which speaking up is belittled and warnings go unheeded.Especially when speaking up entails drawing attention to unpleasantoutcomes, as was the case for Cassandra in her prediction of war, it’seasy for others not to listen or believe. A culture of silence is thus notonly one that inhibits speaking up but one in which people fail tolisten thoughtfully to those who do speak up – especially when theyare bringing unpleasant news.

Consider the Challenger shuttle explosion back in 1986. UnlikeRodney Rocha’s silence in a crucial workplace moment, RogerBoisjoly, an engineer at NASA contractor Morton-Thiokol, didspeak up. The night before the disastrous launch, Boisjoly raised hisconcern that unusually cold temperatures might cause the O-ringsthat connected segments of the shuttle to malfunction. His data wereincomplete and his argument vague, but the assembled group couldhave readily resolved the ambiguity with some simple analyses and


experiments had they listened intensely and respectfully. In short, forvoice to be effective requires a culture of listening.

Let’s take a look at a more recent example of what can happenwhen the listening culture is weak.

Dismissing Warnings

On March 11, 2011, a 9.0 magnitude earthquake occurred off thenortheastern coast of Japan. The quake, later dubbed the “GreatEast Japanese Earthquake,” created tsunami waves up to 45 feethigh that struck the Fukushima Daiichi Nuclear Power Plant.21

Waves of mythic proportions leapt easily over the plant’s undersizedsea walls, flooding the site and completely destroying emergencygenerators, seawater cooling pumps, and the electric wiring system.Without power to cool down the nuclear reactors, three of thereactors overheated, resulting in multiple explosions that injuredworkers on the ground. Most alarmingly, nuclear fuel was releasedinto the ocean, and radionuclides were released from the plant intothe atmosphere. As a result of the nuclear meltdown, hundredsof thousands of Japanese were forced to flee their homes to avoidradiation exposure. Most will be unlikely to ever return home, as it’sestimated the cleanup will take between 30 and 40 years.22

Although the earthquake itself, the most powerful ever recordedin Japan’s history, wreaked unpreventable catastrophic damage thatkilled an estimated 15,000 people,23 it’s now universally acceptedthat the corollary disaster at the nuclear power plant was in factpreventable. By the summer of 2012, an independent investigation,released after having conducted 900 hours of hearings, interviewswith over a thousand people, 9 plant tours, 19 committee meetings,and 3 town halls, concluded that “the accident was clearly man-made” and the “direct causes of the accident were all foreseeable.”24

Examining the evidence, it becomes clear that in the years leadingup to the disaster at the Daiichi Nuclear Power Plant, more thanone Cassandra-like figure spoke up more than once to warn of such


an accident. Recommendations were made for reasonable safetymeasures that would likely have prevented or mitigated the plant’sdestruction. But each time, the warnings were dismissed or notbelieved. The question is, why?

In 2006, Katsuhiko Ishibashi, a professor at the Research Centerfor Urban Safety and Security at Kobe University, was appointed toa Japanese subcommittee tasked with revising the national guidelineson the earthquake-resistance of the country’s nuclear power plants.Ishibashi proposed that the group review the standards for surveyingactive fault lines and criticized the government’s record of allowingthe construction of power plants, like Fukushima Daiichi, in areaswith the potential for such high seismic activity. But the rest of thecommittee, the majority of which consisted of advisors with ties tothe power companies, rejected his proposal and downplayed his con-cerns.25

The following year, Ishibashi spoke up again, publishing a pre-scient article titled Why Worry? Japan’s Nuclear Plants at Grave Riskfrom Quake Damage, with the claim that Japan had been lulled into afalse sense of confidence after many years of relatively quiet seismicactivity. An expert on seismicity and plate tectonics in and aroundthe Japanese islands, he believed that tectonic plates followed regularschedules and that the area in question was overdue for an earth-quake. His warning was explicit: “unless radical steps are taken nowto reduce the vulnerability of nuclear power plants to earthquakes,Japan could experience a true nuclear catastrophe in the near future,”including one caused by tsunamis.26 Unfortunately, others dismissedIshibashi’s warnings. For instance, Haruki Madarame, a nuclear reg-ulator and chairman of Japan’s Nuclear Safety Commission duringthe Fukushima disaster, told the Japanese legislature not to worry, asIshibashi was a “nobody.”27

If Madarame was harsh in his condemnation of Ishibashi as a“nobody,” it’s true that, as an academic rather than an industry or gov-ernment official, he was an outsider. He was, perhaps, not as tightlybound to the dominant post–World War II push for Japan to becomeindependent from its historical dependence on energy imports. Since


the mid-fifties, the island, which has few fossil fuels in the ground,had invested heavily in nuclear energy to diversify its energy supplyfrom oil and achieve greater energy security.28 For the next 40 years,following the 1970s “oil shocks,” and despite the highly publicized1979 Three Mile Island and 1986 Chernobyl accidents, Japan hadworked doggedly and ferociously to develop its own domestic nuclearpower production capacity.29 For instance, the government had pro-vided subsidies and other incentives for rural towns to build plants. Iteven conducted public relations campaigns to convince citizens thatnuclear power was safe.30 Even so, public opinion surrounding nuclearpower remained mixed to negative, with several anti-nuclear demon-strations and the abandonment of several plans to build more plants.31

Given this political context, Ishibashi’s safety concerns may have beenperceived as unpatriotic or meddlesome.

A 2000 in-house study by Tokyo Electric Power Company(TEPCO), the country’s biggest electric company and the ownerof the Fukushima Daiichi plant, did acknowledge the possibilitythat Japan could experience a tsunami of as high as 50 feet. In fact,the report recommended that measures be taken to provide betterprotection from the risks of flooding. However, nothing was everdone because TEPCO thought the risk of such a low probabilityevent was unrealistic.32 Japanese regulators like the Nuclear andIndustrial Safety Agency (NISA) also may have hesitated frompolicing the utilities because, by then, nuclear energy had becomeeven more of a strategic priority for Japan, and increased nuclearpower generation was required to reach the greenhouse gas emissiongoals laid out by the Kyoto protocol. A dozen new plants wereslated to be built by 2011.33 Prior to the Fukushima disaster, Japanwas generating 30% of its electricity via nuclear reactors, and thegovernment planned to increase that percentage to 40% in the yearsto come.34

Although safety issues were ostensibly part of the nuclear powerexpansion plans, retrospective investigations demonstrate that thegovernment and industry culture had not given due credence orconsideration to the gravity of existing threats. For example, in a


June 2009 meeting held by NISA specifically to discuss the readinessof Fukushima Daiichi to withstand a natural disaster, tsunamis werenot even on the agenda. The agency simply did not see them aslikely enough in the Fukushima region to warrant consideration. Increating safety guidelines for Fukushima, the panel thus used datafrom the biggest earthquake on record in the area, a 1938 earthquakethat measured only 7.9 in magnitude and caused only a smalltsunami. Because the reactors at Fukushima Daiichi were locatednear the sea, TEPCO constructed a seawall – one just tall enough tostop a tsunami similar to the one in 1938 from hitting it. The panelassumed that the wall was tall enough to stop any future tsunami andthus focused mainly on preparing the plant for earthquakes.

Another Cassandra-like figure spoke up at that June meeting. Dr.Yukinobi Okamura, the director of Japan’s Active Fault and Earth-quake Research Center, told the panel he disagreed with TEPCO’sdecision.35 He did not think the 1938 quake was big enough to serveas the basis for the Daiichi guidelines and instead brought up a muchearlier example, the Jogan tsunami, which occurred in AD 869 aftera massive earthquake. TEPCO representatives, wishing to discreditOkamura, minimize his concern, or both, claimed the Jogan earth-quake “did not cause much damage.” Okamura insisted otherwise.The Jogan tsunami had destroyed castles and killed at least a thou-sand people. Historical writings compared the tsunami’s fury to wavesthat “raged like nightmares and immediately reached the city center.”Okamura told the panel that he was worried that a tsunami like Jogancould overwhelm the Fukushima region and was confused that thepanel was not using all of the available data.

Instead of listening and taking Okamura’s concerns seriously,as might occur in a culture where psychological safety was high, aTEPCO executive countered that it didn’t make sense to base thesafety recommendations on a legendary earthquake that wasn’t mea-sured by contemporary tools and techniques. Besides, this meetingwas to discuss the risks from earthquakes, rather than tsunamis. Themeeting moved on, with TEPCO executives saying they would tryto learn more. The next meeting, Okamura again tried to convince


the panel of the severity of the threat. He described the predictivemodels his institute had created to show that the current seawallwould not be high enough for anything above an 8.4 magnitudeearthquake, and the detailed surveys they’d performed on the sandleft behind by the Jogan tsunami. In the end, however, the panel didnot listen.

Going Along to Get Along

A culture of silence can thus be understood as a culture in whichthe prevailing winds favor going along rather than offering one’sconcerns. It is based on the assumption that most people’s voicesdo not offer value and thus will not be valued. Perhaps the mostcogent indictment of how a culture of silence perpetuated a set ofattitudes that enabled the Daiichi plant disaster was articulated byKiyoshi Kurokawa, the Chairman of the NAIIC, who wrote at thebeginning of the English version of the report that

For all the extensive detail it provides, what this report cannot fullyconvey – especially to a global audience – is the mindset that supportedthe negligence behind this disaster. What must be admitted – verypainfully – is that this was a disaster “Made in Japan.” Its fundamentalcauses are to be found in the ingrained conventions of Japanese culture: ourreflexive obedience; our reluctance to question authority; our devotionto “sticking with the program”; our groupism; and our insularity.36

Japanese culture does not have a monopoly on any of theingrained conventions that Kurokawa lists. Each one is endemic ofa culture with low levels of psychological safety where the internalreluctance to speak up or push back combines with a very strongdesire to look good to the outside world. Concern with reputationcan silence employees’ voices internally as well as externally. Resis-tance to warnings about the safety about the Fukushima Daiichiplant – and what it would take to install better safety measures – werebound up in national aspirations for nuclear energy.


Similar to what we learned about the FRBNY in Chapter 3,where another powerful set of institutional bodies tacitly colludedto silence the few who dared to speak up, push back, or disagree,Japan’s nuclear power industry suffered regulatory capture. Accord-ing to Kurokawa, Japan’s long-held policy goal to achieve nationalenergy security via nuclear energy became “such a powerful man-date, [that] nuclear power became an unstoppable force, immuneto scrutiny by civil society. Its regulation was entrusted to the samegovernment bureaucracy responsible for its promotion.”37 This blind-ing need and ambition helped create a culture where “it becameaccepted practice to resist regulatory pressure and cover up small-scaleaccidents . . . that led to the disaster at the Fukushima Daiichi NuclearPlant.”38

In 2013, a Stanford study concluded that a mere $50 million couldhave financed a wall high enough to prevent the disaster.39 Yet, thecase shows how very challenging it can be to be heard – to havevoice welcomed, explored, and sometimes acted upon – when thedominant culture does not want to hear the message.

Silence in the Noisy Age of Social Media

On October 15, 2017, actress Alyssa Milano tapped fewer than 140characters into her personal device: “If you’ve been sexually harassedor assaulted write ‘me too’ as a reply to this tweet.” Within 24 hours,the hashtag #MeToo had been tweeted nearly half a million times.40

Although the MeToo movement had been created 10 years earlierby Tarana Burke,41 Milano’s tweet, posted in the context of a slewof recent and highly publicized sexual harassment accusations leveledagainst celebrities, ignited a social media activism campaign. The goal:the simple act of speaking up. Women and men from all walks of lifewho had suffered myriad types of unwanted sexual attention, oftenegregious and persistent, the majority afraid to tell even their closestrelations, were emboldened to tweet, post, and message about theirexperiences in what became a public forum.


Milano’s tweet was hardly the first act of speaking up. Ninemonths earlier, on February 19, 2017, the social media landscapewas emblazoned by a 3000-word blog post written by a youngsoftware engineer.42 Susan Fowler, who had recently left her jobas a site-reliability engineer at the ride-sharing company Uber,was exercising her right to candor on her personal website. Thespecificity and honesty with which she described her experience,which she called “a strange, fascinating, and slightly horrifyingstory,” reveals much about how mechanisms of power and silencecan perpetuate a psychologically unsafe culture. Fowler’s voice,echoed by some of her colleagues, amplified by social media, andmade louder still by mainstream press, tells us how an unsafe culturecan ultimately become unsustainable.

On her first day at the company, Fowler’s manager sent her a seriesof inappropriate messages over the company’s chat system. The man-ager told her “he was looking for women to have sex with.” Fowlersaid, “It was clear that he was trying to get me to have sex withhim . . . ” She took screenshots of the messages and reported the man-ager to HR. But things didn’t go as she expected. Both HR and uppermanagement informed Fowler that it was “this man’s first offense, andthat they wouldn’t feel comfortable giving him anything other than awarning and a stern talking-to” because he “was a high performer.”Fowler was given the choice of either finding another team to workon or remaining on her present team with the understanding that hermanager would “most likely give [her] a poor performance reviewwhen review time came around, and there was nothing they could doabout that.” Fowler tried to protest this “choice,” but got nowhere,and ultimately ended up switching teams.

Over the next few months, Fowler met other women engineerswho had similar experiences of sexual harassment at Uber. They hadalso reported these to HR and gotten nowhere. Some of the womeneven reported having similar interactions with the same manager asFowler. All were told it was his first offense. In each case, nothingwas done. Fowler and her colleagues, feeling unheard, fell silent –for a while.


Ironically, as reported in her blog post, Fowler had been initiallyexcited about joining Uber back in November 2015, citing that shehad “the rare opportunity to choose whichever team was working onsomething that I wanted to be part of.”

Promoted and Protected

Uber Technologies, Inc., founded in 2009 by serial entrepreneurs andfriends Garrett Camp and Travis Kalanick, had launched in San Fran-cisco in 2011 with funding from prominent Silicon Valley venturecapital firms.43 As Uber grew, so did its reputation as an aggressive,fast-moving, in-your-face company, not inconsistent with its overtintention to disrupt the long-established taxicab industry, replacingit with a ride-sharing economy.44 Top employees were “promotedand protected” – as long as they could hit or exceed their numbers,they were rewarded.45 After Fowler’s post broke, current and formeremployees came forward to describe Uber’s culture as “unrestrained,”a “Hobbesian environment . . . in which workers are sometimes pit-ted against one another and where a blind eye is turned to infractionsfrom top performers.”46 Fowler’s manager had merely been a case inpoint.

Fowler, like other new Uber hires, had been advised of thecompany’s core values.47 Several of those values were likely to havecontributed to a psychologically unsafe environment. For example,“super-pumpedness,” especially central to the company, involved acan-do attitude and doing whatever it took to move the companyforward. This often meant working long hours, not in itself ahallmark of a psychologically unsafe environment; Fowler seems tohave relished the intellectual challenges and makes a point to say thatshe is “proud” of the engineering work she and her team did. Butsuper-pumpedness, with its allusions to the sports arena and malehormones, seems to have been a harbinger of the bad times to come.


Another core value was to “make bold bets,” which was interpretedas asking for forgiveness rather than permission. In other words, itwas better to cross a line, be found out wrong, and ask for forgivenessthan it was to ask permission to transgress in the first place. Anothervalue, “meritocracy and toe-stepping,” meant that employees wereincented to work autonomously, rather than in teams, and causepain to others to get things done and move forward, even if it meantdamaging some relationships along the way.48

You may ask, so what? The same company that silenced, hurt,and eventually lost hardworking and talented engineers such as SusanFowler was still tremendously successful in getting millions of peopleto speak with a new vocabulary word – “to uber.” The company’sgrowth was exponential and as of early 2018 is valued at north of $70billion.49 Maybe a bit of super-pumpedness and a little toe-steppingis just what it takes today to get ahead?

One problem is that social media enables a new kind of speakingup that makes it that much harder for companies to actively andshamelessly advocate for a psychologically unsafe culture. Fowler’sexposé sent reporters running to investigate. The New York Timesinterviewed over 30 current and former Uber employees andreported on numerous incidents of harassment, some as egregiousas an Uber manager who “groped female co-workers’ breasts ata company retreat in Las Vegas” and “a director [who] shouted ahomophobic slur at a subordinate during a heated confrontationin a meeting.”50 According to Fowler, when she joined Uber,the engineering site reliability organization was over 25% women,but before she left it had dropped to 6%. In the aftermath andreckoning that followed Fowler’s blog, multiple lawsuits ensued,massive numbers of employees at all levels were either fired or left oftheir own accord, and the company’s valuation and reputation fell farand fast.51 A second problem is that people suffer unnecessary harm.

On June 21, 2017, Travis Kalanick stepped down as Uber’sCEO after five of its major shareholders demanded his resignation.52


Although Fowler petitioned the United States Supreme Court toconsider her experience at Uber in its decision on whether employ-ees can forfeit rights to collective litigation in their employmentcontracts, the proposal was later voted down.53 That year, she wasfeatured on the cover of TIME Magazine as one of its “Person(s) of theYear” as one of five “Silence Breakers” who spoke out about sexualharassment in 2017.54 She was also named The Financial Times “Per-son of the Year 2017,”55 one of Vanity Fair’s “New Establishments,”56

and No. 2 on Recode’s Top 100, behind only Jeff Bezos.57

Susan Fowler at Uber is just one example of how social mediahas enabled the speaking of truth to power in the workplace. In2017, thousands of women spoke up to say, “Me Too,” to workplaceharassment, and hundreds of men in high-profile positions sufferedthe consequences of behavior that had, in many cases, worked forawhile – decades, or even entire careers. Communication technologygave social media movements such as MeToo and Black Lives Matterthe power to ignite and move with rapidity into mainstream media,public opinion, and in some cases, into the legal courts. Such move-ments raise the sense of urgency to create and maintain organizationswhere psychological safety supports people to do their best work.

When Uber’s new CEO, Dara Khosrowshahi, first came on boardin August 2017, one of his priorities was to meet with women engi-neers. Alert to the damage done to the company’s culture, he beganby laying the groundwork for a psychologically safe workplace. AsJessica Bryndza, Uber’s Global Director of People Experience, com-mented, “He [Khosrowshahi] didn’t come in guns blazing. He camein listening.”58

The operative word here is “listening.” In the Chapters 5 and 6,you will read about eight flourishing organizations where leaders havecreated the conditions to make listening and speaking up the norm,not the exception. In these fearless workplaces, it’s far less likely thatemployees will refrain from sharing valuable information, insights, orquestions and far more likely that leaders will listen to rather thandismiss bad news or early warnings.


Chapter 4 Takeaways

◾ When people fail to speak up with their concerns or ques-tions, the physical safety of customers or employees is at risk,sometimes leading to tragic loss of life.

◾ Excessive confidence in authority is a risk factor in psycholog-ical and physical safety.

◾ A culture of silence is a dangerous culture.

Endnotes

1. Harris. S.J. “Syd Cannot Stand Christmas Neckties.” The AkronBeacon Journal. January 5, 1951, pp. 6. https://www.newspapers.com/newspage/147433987/ Accessed July 23, 2018

2. Roberto, M.A, Edmondson, A.C., &. Bohmer, R.J., Columbia’s FinalMission. Case Study. HBS No. 304-090. Boston, MA: Harvard Busi-ness School Publishing, 2004.

3. Whitcraft, D., Katz, D., & Day, T. (Producers). “Columbia: Final Mis-sion,” ABC Primetime. New York: ABC News, 2003.

4. National Aeronautics and Space Administration. Columbia Acci-dent Investigation Board: Report Volume 1. Washington, D.C.: U.S.Government Printing Office, 2003.

5. Whitcraft, D. et al. 2003, op cit.6. The story of the disaster on Tenerife in this chapter draws on a number

of sources produced by Jan Hagen and his colleagues, including:◾ Schafer, U., Hagen, J., & Burger, C. Mr. KLM (A): Jacob Veld-

huyzen. Case Study. ESMT No. 411-0117. Berlin, Germany: Euro-pean School of Management and Technology, 2011.

◾ Schafer, U., Hagen, J., & Burger, C. Mr. KLM (B): Captain van Zan-ten. Case Study. ESMT No. 411-0118. Berlin, Germany: EuropeanSchool of Management and Technology, 2011.

◾ Schafer, U., Hagen, J., & Burger, C. Mr. KLM (C): Jaap. Case Study.ESMT No. 411-0119. Berlin, Germany: European School of Man-agement and Technology, 2011.

◾ Hagen, J.U. Confronting Mistakes: Lessons From The Aviation IndustryWhen Dealing with Error. United Kingdom: Palgrave Macmillan UK,2013. Print.

https://www.newspapers.com/newspage/147433987/

https://www.newspapers.com/newspage/147433987/


7. Royal Dutch Airlines is Koninklijke Luchtvaart Maatschappij in Dutch,abbreviated as KLM.

8. The dialogue reported in this story was captured by the cockpit voicerecorders of both planes involved in the collision and reported inAppendix 6 of the following investigation report: Air Line PilotsAssociation. Aircraft accident report: Human factors report on the Tenerifeaccident, Tenerife, Canary Islands, March 27, 1977. Washington D.C.:Engineering and Air Safety, 1977.

9. For history and background on CRM, refer to Alan Diehl’s book on airsafety: Diehl, A.E. Air Safety Investigators: Using Science to Save Lives – OneCrash at a Time. United States: XLIBRIS, 2013. Print.

10. The story of Betsy Lehman’s death at the Dana-Farber Cancer Institutein this chapter draws on information from a case study by my colleagueRichard Bohmer: Bohmer, R. & Winslow, A. The Dana-Farber CancerInstitute. Case Study. HBS Case No. 699-025. Boston, MA: HarvardBusiness School Publishing, 1999.

11. The Boston Globe broke the Lehman story and continued to follow itclosely in the months and years that followed. Richard Knox, who waslater sued for his coverage of the incident, wrote the first article aboutthe error: Knox, R.A. “Doctor’s Orders Killed Cancer Patient.” TheBoston Globe, March 23, 1995.

12. Bohmer, R. & Winslow, A. 1999: 8.13. Gorman, C. & Mondi, L. “The disturbing case of the cure that killed

the patient.” TIME Magazine. April 3, 1995: 60. http://content.time.com/time/magazine/article/0,9171,982768,00.html AccessedJune 14, 2018.

14. Bohmer, R. & Winslow, A. 1999, op cit.15. Ibid.16. Knox, March 23, 1995, op cit.17. Ibid.18. Ibid.19. Ibid.20. Knox, R.A. “Dana-Farber puts focus on mistakes in overdoses.” The

Boston Globe. October 31, 1995. https://www.highbeam.com/doc/1P2-8310418.html Accessed June 12, 2018.

21. Details on the disaster at Fukushima Daiichi come from multiple reports:◾ Fukushima Nuclear Accident Independent Investigation Commis-

sion (NAIIC). “Official Report of the Fukushima Nuclear Accident

http://content.time.com/time/magazine/article/0,9171,982768,00.html

http://content.time.com/time/magazine/article/0,9171,982768,00.html

https://www.highbeam.com/doc/1P2-8310418.html

https://www.highbeam.com/doc/1P2-8310418.html


Independent Investigation Commission: Executive Summary.”National Diet of Japan. 2012. https://www.nirs.org/wp-content/uploads/fukushima/naiic_report.pdf Accessed June 12, 2018.

◾ Amano, Y. “The Fukushima Daiichi Accident: Report by theDirector General.” International Atomic Energy Agency Report. 2015.https://www-pub.iaea.org/MTCD/Publications/PDF/Pub1710-ReportByTheDG-Web.pdf Accessed June 12, 2018.

22. Amano, Y. 2015, op cit.23. Ibid.24. Fukushima NAIIC. 2012: 16.25. Clenfield, J. & Sato, S. “Japan Nuclear Energy Drive Compromised

by Conflicts of Interest.” Bloomberg. December 12, 2007. http://www.bloomberg.com/apps/news?pid=newsarchive&sid=awR8KsLlAcSoAccessed June 12, 2018.

26. Ishibashi, K. “Why Worry? Japan’s Nuclear Plants at Grave Risk FromQuake Damage.” The Asia-Pacific Journal. August 1, 2007. https://apjjf.org/-Ishibashi-Katsuhiko/2495/article.html Accessed June 12, 2018.

27. Clenfield, J. “Nuclear Regulator Dismissed Seismologist on JapanQuake Threat.” Bloomberg.com. November 21, 2011. https://www.bloomberg.com/news/articles/2011-11-21/nuclear-regulator-dismissed-seismologist-on-japan-quake-threat Accessed June 12,2018.

28. World Nuclear Association. “Nuclear Power in Japan.” World-Nuclear.orgwww.world-nuclear.org/information-library/country-profiles/countries-g-n/japan-nuclear-power.aspx. Accessed June 4, 2018.

29. Ibid.30. Aldrich, D.P. “With a Mighty Hand.” The New Republic. March 19,

2011. https://newrepublic.com/article/85463/japan-nuclear-power-regulation Accessed June 11, 2018.

31. See, for instance: BBC News. “Japan cancels nuclear power plant.” BBCNews. February 22, 2000. http://news.bbc.co.uk/2/hi/asia-pacific/652169.stm Accessed June 10, 2018.

32. Tokyo Electric Power Company. “Fukushima Nuclear AccidentSummary & Nuclear Safety Reform Plan” Tokyo Electric PowerCompany, Inc. March 29, 2013: 19. As the company wrote in thisreport after the Fukushima disaster: “in June and July of [2000], thecost of constructing flooding embankment to protect against tsunamiand the impact on surrounding areas were evaluated. The reliability

https://www.nirs.org/wp-content/uploads/fukushima/naiic_report.pdf

https://www.nirs.org/wp-content/uploads/fukushima/naiic_report.pdf

https://www-pub.iaea.org/MTCD/Publications/PDF/Pub1710-ReportByTheDG-Web.pdf

https://www-pub.iaea.org/MTCD/Publications/PDF/Pub1710-ReportByTheDG-Web.pdf

http://www.bloomberg.com/apps/news?pid=newsarchive&sid=awR8KsLlAcSo

http://www.bloomberg.com/apps/news?pid=newsarchive&sid=awR8KsLlAcSo

https://apjjf.org/-Ishibashi-Katsuhiko/2495/article.html

https://apjjf.org/-Ishibashi-Katsuhiko/2495/article.html

https://www.bloomberg.com/news/articles/2011-11-21/nuclear-regulator-dismissed-seismologist-on-japan-quake-threat



www.world-nuclear.org/information-library/country-profiles/countries-g-n/japan-nuclear-power.aspx

www.world-nuclear.org/information-library/country-profiles/countries-g-n/japan-nuclear-power.aspx

https://newrepublic.com/article/85463/japan-nuclear-power-regulation

https://newrepublic.com/article/85463/japan-nuclear-power-regulation

http://news.bbc.co.uk/2/hi/asia-pacific/652169.stm

http://news.bbc.co.uk/2/hi/asia-pacific/

http://news.bbc.co.uk/2/hi/asia-pacific/652169.stm

http://Bloomberg.com

http://World-Nuclear.org


of the computational result was also discussed.” But they ultimatelyconcluded that the “technological validity” of such a model could notbe verified, and did nothing more.

33. World Nuclear Association. “Nuclear Power in Japan,” op cit.34. Ibid.35. All information from the Okamura story is from Clarke, R. & Eddy,

R.P. Warnings: Finding Cassandras to Stop Catastrophes. HarperCollinsPublishing, 2017, Chapter 5, pp. 75-98.

36. Fukushima NAIIC. 2012: 937. Ibid.38. Ibid.39. Lipscy, P.Y., Kushida, K.E., & Incerti, T. “The Fukushima Disaster

and Japan’s Nuclear Plant Vulnerability in Comparative Perspective.”American Chemical Society: Environmental Science & Technology, (2013): 47,6082–6088.

40. Gilbert, S. “The Movement of #MeToo: How a Hashtag Got ItsPower.” The Atlantic. October 16, 2017. https://www.theatlantic.com/entertainment/archive/2017/10/the-movement-of-metoo/542979/ Accessed June 14, 2018.

41. Garcia, S.E. “The Woman Who Created #MeToo Long BeforeHashtags.” The New York Times. October 20, 2017. https://www.nytimes.com/2017/10/20/us/me-too-movement-tarana-burke.htmlAccessed June 13, 2018.

42. Fowler, S. “Reflecting on One Very, Very Strange Year at Uber.” SusanFowler personal site. February 19, 2017. https://www.susanjfowler.com/blog/2017/2/19/reflecting-on-one-very-strange-year-at-uberAccessed June 5, 2018

43. Several details on Uber were taken from a case written by my friend JayLorsch and colleagues: Srinivasan, S., Lorsch, J.W., & Pitcher, Q. Uberin 2017: One Bumpy Ride. Case Study. HBS No. 117-070. Boston,MA: Harvard Business School Publishing, 2017.

44. Isaac, M. “Inside Uber’s Aggressive, Unrestrained Workplace Culture.”The New York Times. February 22, 2017. https://www.nytimes.com/2017/02/22/technology/uber-workplace-culture.html Accessed June13, 2018.

45. Isaac, M. “Uber’s C.E.O. Plays With Fire.” The New York Times. April23, 2017. https://www.nytimes.com/2017/04/23/technology/travis-kalanick-pushes-uber-and-himself-to-the-precipice.html AccessedJune 13, 2018.

46. Isaac, M. February 22, 2017, op cit.

https://www.theatlantic.com/entertainment/archive/2017/10/the-movement-of-metoo/542979/



https://www.nytimes.com/2017/10/20/us/me-too-movement-tarana-burke.html

https://www.nytimes.com/2017/10/20/us/me-too-movement-tarana-burke.html

https://www.susanjfowler.com/blog/2017/2/19/reflecting-on-one-very-strange-year-at-uber

https://www.susanjfowler.com/blog/2017/2/19/reflecting-on-one-very-strange-year-at-uber

https://www.nytimes.com/2017/02/22/technology/uber-workplace-culture.html

https://www.nytimes.com/2017/02/22/technology/uber-workplace-culture.html

https://www.nytimes.com/2017/04/23/technology/travis-kalanick-pushes-uber-and-himself-to-the-precipice.html

https://www.nytimes.com/2017/04/23/technology/travis-kalanick-pushes-uber-and-himself-to-the-precipice.html


47. Quora. “What Are Uber’s 14 Cultural Values?” Quora, https://www.quora.com/What-are-Ubers-14-core-cultural-values

48. Ibid.49. Schleifer, T. “Uber’s latest valuation: $72 billion.” Recode. February

9, 2018. https://www.recode.net/2018/2/9/16996834/uber-latest-valuation-72-billion-waymo-lawsuit-settlement Accessed June 13,2018.

50. Isaac, M. February 22, 2017, op cit.51. Srinivasan, S., Lorsch, J.W., & Pitcher, Q. Uber in 2017: One Bumpy

Ride. Case Study. HBS No. 117-070. Boston, MA: Harvard BusinessSchool Publishing, 2017.

52. Isaac, M. “Uber Founder Travis Kalanick Resigns as C.E.O.” The NewYork Times. June 21, 2017. https://www.nytimes.com/2017/06/21/technology/uber-ceo-travis-kalanick.html Accessed June 13, 2018.

53. Blumberg, P. “Ex-Uber Engineer Asks Supreme Court to Learn FromHer Ordeal.” Bloomberg.Com. August 24, 2017; Hurley, L. “Companieswin big at U.S. top court on worker class-action curbs.” Reuters. May21, 2018.

54. Kim, L. “Two Bay Area Women on Time Cover for ‘Person of theYear.’” ABC7 San Francisco. December 7, 2017.

55. Hook, L. “FT Person of the Year: Susan Fowler.” Financial Times.December 12, 2017.

56. Morse, B. “Elon Musk, Susan Fowler, and Mark Zuckerberg Join Tech’sBiggest Names in ‘New Establishment’ List.” Inc.com. October 2, 2017.https://www.inc.com/brittany-morse/elon-musk-susan-fowler-and-markzerberg-join-big-tech-names-in-new-establishment-list.htmlAccessed June 8, 2018.

57. Bhuiyan, J. “With Just Her Words, Susan Fowler Brought Uber to ItsKnees.” Recode, December 6, 2017. https://www.recode.net/2017/12/6/16680602/susan-fowler-uber-engineer-recode-100-diversity-sexual-harassment Accessed June 12, 2018.

58. Kerr, D. “Uber’s U-Turn: How the New CEO Is Cleaning House afterScandals and Lawsuits.” C-NET. April 27, 2018. https://www.cnet.com/news/ubers-u-turn-how-ceo-dara-khosrowshahi-is-cleaning-up-after-scandals-and-lawsuits/ Accessed June 14, 2018.

https://www.quora.com/What-are-Ubers-14-core-cultural-values

https://www.quora.com/What-are-Ubers-14-core-cultural-values

https://www.recode.net/2018/2/9/16996834/uber-latest-valuation-72-billion-waymo-lawsuit-settlement

https://www.recode.net/2018/2/9/16996834/uber-latest-valuation-72-billion-waymo-lawsuit-settlement

https://www.nytimes.com/2017/06/21/technology/uber-ceo-travis-kalanick.html

https://www.nytimes.com/2017/06/21/technology/uber-ceo-travis-kalanick.html

https://www.inc.com/brittany-morse/elon-musk-susan-fowler-and-markzerberg-join-big-tech-names-in-new-establishment-list.html

https://www.inc.com/brittany-morse/elon-musk-susan-fowler-and-markzerberg-join-big-tech-names-in-new-establishment-list.html

https://www.recode.net/2017/12/6/16680602/susan-fowler-uber-engineer-recode-100-diversity-sexual-harassment



https://www.cnet.com/news/ubers-u-turn-how-ceo-dara-khosrowshahi-is-cleaning-up-after-scandals-and-lawsuits/



http://Bloomberg.com

http://Inc.com

5The FearlessWorkplace

The only thing we have to fear is fear itself.—Franklin D. Roosevelt1

Perhaps the truly fearless workplace is an impossibility. People arenaturally averse to losing their standing in the eyes of peers and bosses.Nonetheless, a growing number of organizations are making the fear-less workplace an aspiration. Leaders of these organizations recognizethat psychological safety is mission critical when knowledge is a cru-cial source of value. In that sense, the fearless organization is some-thing to continually strive toward rather than to achieve once and forall. It’s a never-ending and dynamic journey.

In this chapter I describe the practices and culture that a handfulof successful companies have worked hard to create - to show howpsychological safety works. When people speak up, ask questions,debate vigorously, and commit themselves to continuous learning andimprovement, good things happen. It’s not that it’s easy, or alwaysenjoyable, but as you will see in the pages ahead, investing the effort

103


and living with the challenges pays off. Workplaces where employeesknow that their input is valued create new possibilities for authenticengagement and stellar performance.

The organizations profiled in this chapter thus provide a glimpseinto what psychologically safe workplaces look like; they show whathappens – for the quality of the product, for customers, and for share-holders – when employees are freed up to express their ideas, ques-tions, and concerns. Fewer in number than their more fearful coun-terparts, these organizations boast a hidden source of competitiveadvantage, which plays out in a variety of ways, depending on theindustry, the company leaders, and the nature of the work.

As we will see, there is more than one way in which psycholog-ical safety manifests in the workplace. When a team, department, ororganization gets psychological safety right, it can seem remarkablystraightforward, especially when compared to the stories of peoplenavigating the interpersonal and conversational complexities createdby fear and distrust. For this reason, you may notice the relative sim-plicity of these “good news” stories. You’ll hear more from leaders, intheir own words, in this chapter, about their visions and philosophiesabout effective workplaces in a fast-paced world. This is because theindividuals you’ll meet in the pages ahead tended to have thoughtdeeply to inform conscious decisions about creating workplaces tobring out the best in people.

The companies profiled in this chapter range from the creativefields of film and fashion to high-tech computing and finance tomachine manufacturing. Yet, for all the striking differences, each ofthe companies profiled relies on employee learning, ingenuity andengagement for its success.

Making Candor Real

If you were over the age of three in 1995, chances are you wereaware – or would soon become aware – of a movie called Toy Story,the first computer animated feature film released by a company named

The Fearless Workplace 105

Pixar. That year, Toy Story would become the highest grossing filmand Pixar the largest initial public offering.2 The rest, as they say, ishistory. Pixar Animation Studios has since produced 19 feature films,all of which have been commercial and critical triumphs. This is aremarkable statement in an industry where hits are prized but rare, anda series of hits without fail from a single company is all but unheardof. How do they do it? Through leadership that creates the conditionswhere both creativity and criticism can flourish. Pixar may be in thebusiness of creating and animating stories, but the way the companyworks offers lessons about psychological safety that, much like theirmovies, are universal.

Pixar co-founder Ed Catmull credits the studio’s success, in part,to candor. His definition of candor as forthrightness or frankness3 andhis insight that we associate the word “candor” with truth-telling anda lack of reserve support psychological safety’s tenets. When candoris part of a workplace culture, people don’t feel silenced. They don’tkeep their thoughts to themselves. They say what’s on their mindsand share ideas, opinions, and criticisms. Ideally, they laugh togetherand speak noisily. Catmull encourages candor by looking for ways toinstitutionalize it in the organization – most notably, in what Pixarcalls its “Braintrust.”

A small group that meets every few months or so to assess a moviein process, provide candid feedback to the director, and help solvecreative problems, the Braintrust was launched in 1999, when Pixarwas rushing to save Toy Story 2, which had gone off the rails. TheBraintrust’s recipe is fairly simple: a group of directors and storytellerswatches an early run of the movie together, eats lunch together, andthen provides feedback to the director about what they think workedand what did not. But the recipe’s key ingredient is candor. And can-dor, though simple, is never easy.

Embracing the bad on the journey to good

As Catmull candidly admits, “ . . . early on, all of our movies suck.”4

In other words, it would have been easy to make Toy Story a movie


about the secret life of toys that was sappy and boring. But the creativeprocess, innately iterative, relies on feedback that is truly honest. Ifthe people in the Braintrust room had murmured words of politepraise for early screenings rather than feeling safe enough to candidlysay what they felt was wrong, missing, or unclear or made no sense,chances are that Toy Story and Toy Story 2 would not have soared intothe cinematic stratosphere.

Pixar’s Braintrust has rules. First, feedback must be construc-tive – and about the project, not the person. Similarly, the filmmakercannot be defensive or take criticism personally and must be readyto hear the truth. Second, the comments are suggestions, notprescriptions. There are no mandates, top-down or otherwise; thedirector is ultimately the one responsible for the movie and can takeor leave solutions offered. Third, candid feedback is not a “gotcha”but must come from a place of empathy. It helps that the directorshave often already gone through the process themselves. Praise andappreciation, especially for the director’s vision and ambition, aredoled out in heaping measures. Catmull, again: “The Braintrustis benevolent. It wants to help. And it has no selfish agenda.”5

The Braintrust, seen as a neutral and free-floating “it” rather thanas a fearsome “them,” is perceived as more than the sum of itsindividual members. When people feel psychologically safe enoughto contribute insight, opinion, or suggestion, the knowledge in theroom thereby increases exponentially. This is because individualobservations and suggestions build on each other, taking new shapeand creating new value, especially compared to what happens whenindividual feedback is collected separately.

Braintrusts – groups of people with a shared agenda who offercandid feedback to their peers – are subject to individual personali-ties and chemistries. In other words, they can easily go off the rails ifthe process isn’t well led. To be effective, managers have to monitordynamics continually over time. It helps enormously if people respecteach other’s expertise and trust each other’s opinions. Pixar directorAndrew Stanton offers advice for how to choose people for an effec-tive feedback group. They must, he says, “make you think smarter and


put lots of solutions on the table in a short amount of time.”6 Stan-ton’s point about having people around who make us “think smarter”gets to the heart of why psychological safety is essential to innovationand progress. We can only think smarter if others in the room speaktheir minds.

Sadly, a caveat is necessary here. In late 2017, Ed Catmull’sco-founder and Pixar’s chief creative officer, John Lasseter, steppeddown for behavioral misconduct and apologized in an email to“anyone who has ever been on the receiving end of an unwantedhug or any other gesture they felt crossed the line in any way, shapeor form.”7 Complaints by individual Pixar employees about Lasseter’sharassment soon followed. Lasseter’s behavior and consequent outing,part of the MeToo movement, which I will discuss in Chapter 6,underscores the fragile and temporal nature of psychological safety.Unwanted physical attention easily undermines hard-earned trust.

The Braintrust resembles what the academic community callspeer review – a process by which other experts in the field readand offer constructive criticism on a colleague’s article draft or bookin-progress. This can be invaluable input for improvement, andit’s almost always the case that a published article is vastly betterthan the original submitted manuscript. However, academic peerreview also can be competitive and unfriendly – especially whenanonymous – and these are attributes that the Braintrust, at its best,defiantly lacks. Pixar’s method also resembles “art crits” (critiques),in which a group of art students, usually led by a professor orprofessional artist, offers candid critical comments on one another’swork. Although art crits – like any group process – can veer intoa domain of low psychological safety when the honesty becomesdestructive and is not accompanied by empathic support,8 this is notnecessarily The case; peer feedback is valuable enough for youngartists to self-organize.9 Imagine if the ill-fated Volkswagen dieselengine had been subject to a braintrust of engineers who could haveoffered candid feedback on its feasibility rather than a secretive groupwho worked in fear of failure. Things might have turned out quitedifferently.


Freedom to Fail

Failure is another ingredient Catmull cites as crucial to Pixar’s expo-nential numbers at the box office. That might sound odd, in that thelast thing Pixar wants is a box office flop. But avoiding that outcomeis understood to be dependent on embracing failure earlier in the cre-ative journey. The Braintrust views risk and failure as a necessary partof the creative process. In its early stages a film will “suck” accordingto Catmull. Stanton compares the process of moviemaking to thatof learning to ride a bicycle; no one learns how to pedal gracefullywithout falling over a few times.10 Catmull believes that without thefreedom to fail people “will seek instead to repeat something safethat’s been good enough in the past. Their work will be derivative,not innovative.”11 As in so many other contexts, experimentation andits inevitable trial-and-error process are necessary to innovation.

Catmull is honest and human in acknowledging that failure hurts.Embracing failure is far easier to say than to actually put into practice!“To disentangle the good and bad parts of failure,” he says, “we haveto recognize both the reality of the pain and the benefit of the result-ing growth.”12 He points out that it’s not enough to simply acceptfailure when it happens and move on, more or less hoping to avoid itgoing forward. We need to understand failure not as something to fearor try to avoid, but as a natural part of learning and exploration. Justas learning to ride a bike entails the physical discomfort of skinnedknees or bruised elbows, creating a stunningly original movie requiresthe psychological pain of failure. Moreover, trying to avoid the painof failure in learning will lead to far worse pain. Catmull: “for lead-ers especially, this strategy – trying to avoid failure by outthinkingit – dooms you to fail.”13

Failure can, of course, be costly, and Pixar is strategic in seekingto have failures occur early in the process by, for example, allowingdirectors to spend years in the development phase, which involvesexpenditures of salaries but limits excess production costs. Howdo you know when failure isn’t productive? When is it better tocut losses and give up? According to Catmull, when a project isn’t


working out, the only reason Pixar will fire a director is if the directorhas clearly lost the confidence of his or her team or has receivedconstructive feedback in a Braintrust meeting and refused to act onit for a prolonged period. In this way, Pixar tries to institutionalizewhat Catmull calls “uncouple[ing] fear and failure”14 by creatingan environment where psychological safety is high enough that a“making mistakes doesn’t strike terror into employees’ hearts.” Ofcourse, Pixar is not alone in embracing candor and failure. In fact, it’slikely that any successful creative endeavor does this, either implicitlyor explicitly. The enormously successful (and controversial) RayDalio of Bridgewater Associates, one of the world’s largest hedgefunds, provides another example.

Extreme Candor

In 1975, a twentysomething Ray Dalio founded Bridgewater Asso-ciates in his two-bedroom New York City apartment. Since then,the firm has grown to over 1500 employees, earned consistentlyhigh returns (even during the 2008–2009 financial crisis), and beenthe recipient of dozens of industry awards. Dalio has been on theForbes 400 list and TIME Magazine’s 100 most influential people. Heattributes Bridgewater’s success to its culture of “valuing meaningfulwork and meaningful relationships,” which has been achievedthrough “radical truth and transparency.”15 In 2011–2012, as partof a plan to preserve the firm’s culture, Dalio created a documenttitled Principles to record the tried-and-true ideas, methods, andprocesses that he’d developed.16 Now a best-selling book,17 Principlesprovides a detailed and extensive guide to one way – by no means theonly way – that psychological safety can work to promote learning,innovation, and growth.

Dalio’s extreme candor begins with his principle that leaders must“create an environment in which . . . no one has the right to hold acritical opinion without speaking up about it.”18 Note the use of theword “right.” The framing here is an ethical one. At Bridgewater,


if you think it, you must say it. No holding back. In Dalio’s view,candor is always in service to the truth, no matter how painful,because only by facing the truth can you take effective action toproduce good outcomes. By way of example, he points out that if aperson has a terminal illness, it’s better to know the truth, no matterhow frightening, because only then can one figure out what to do.19

In framing silence as an unethical choice, Dalio is taking a moreextreme stance than I have adopted. But it’s worth reflecting on thisidea, which to me implies that you owe your colleagues the expressionof your opinion or ideas; in a sense, those ideas belong to the collectiveenterprise, and you therefore don’t have the right to hoard them.

Candid feedback at Bridgewater is thus constant and detailed.Every employee is required to keep an Issue Log, which recordsindividual mistakes, strengths and weaknesses, and a “pain button,”which records the employee’s reaction to specific criticisms as well astheir changes in behavior to remedy weaknesses, and whether thosechanges were effective.

Transparency Libraries

Radical transparency and extreme candor go hand in hand at Bridge-water. There’s even a prohibition on talking about people who arenot present and thus cannot learn from what’s being said. Managersare not supposed to talk about their supervisees if the person is notin the room. In Dalio’s words, “If you talk behind people’s backsat Bridgewater you are called a slimy weasel.”20 A tally of ongoingassessment statistics for each employee are kept on “baseball cards,”publicly available to everyone in the firm, and used by managers formaking decisions around compensation, incentives, promotions, andfiring. No one at the firm, including Dalio, can hide behind opacity.A “transparency library” containing videos of every executive meet-ing, is available for viewing in case employees want to see how policiesor initiatives were discussed.


Dalio’s views on the need for error and smart failures as a part ofthe learning process are consistent with what we know about howgrowth and innovation occur. He believes that “our society’s ‘mis-takephobia’ is crippling”21 because, beginning in elementary school,we are taught to seek the right answer instead of learning to learnfrom mistakes as a pathway to innovative and independent thinking.Early on, he says he “learned that everyone makes mistakes and hasweaknesses and that one of the most important things that differen-tiates people is their approach to handling them.” For that reason, atBridgewater, “it is okay to makes mistakes, but unacceptable not toidentify, analyze, and learn from them.”22

Productive Conflict

Candor, transparency, and learning from error – a psychological safetytriad – are emphasized in Dalio’s Principles as scaffolding for both hislife and his company. To that list we can add conflict resolution, animportant input to innovation and good decision-making for whichpsychological safety is sorely needed. Conflict, in the Bridgewaterculture, is conducted in the service of finding “what is true and whatto do about it.”23 It involves having task-based conversations aboutwho will do what, as well as exchanging alternate points of viewand overcoming differences or misunderstandings. Recognizing theinnate human tendency to treat a conflict as a contest, Dalio offersup advice, such as, “don’t try to ‘win’ the argument. Finding outthat you are wrong is even more valuable than being right, becauseyou are learning.”24 It’s important to know when to move on froma disagreement and not spend too much time on trivial details.He concedes that “open-minded disagreements” are frequent atBridgewater, and, naturally, people sometimes do get angry. (Notsurprisingly, new employees at Bridgewater have a high attritionrate; the culture is not for everybody). Managers are advised to“enforce the logic of conversations” when people’s emotions get too


hot to handle; this is best done by remaining “calm and analytical inlistening to others’ points of view.”25

Dalio distinguishes between three categories of conversa-tion – debate, discussion, and teaching – and advises that managersevaluate explicitly which method of discourse is most appropriatefor the issue at hand. Discussion, according to Dalio, is an openexploration of ideas and possibilities and involves people with varyinglevels of experience and authority in the organization. In a discus-sion, everyone is encouraged to ask questions, offer opinions, andmake suggestions. All views are welcomed and considered. Debate,however, takes place between “approximate equals,” and teachingtakes place between people with “different levels of understanding.”While the boundaries between debate, discussion, and teachingmay often be fluid in a fearless organization – communications maycombine all three categories – these three categories offer usefulways of thinking about and structuring how to speak to one anotherin a psychologically safe environment.

We see here that explicit hierarchy and psychological safety are notmutually exclusive in a fearless organization. While the Bridgewaterenvironment is clearly one where people must get used to speaking upoften and openly, speaking up coexists with a hierarchy that is based inpart on individual track records. But decision-making is not by con-sensus. Like Pixar’s Brainstrusts, open debate’s purpose is to providethe lead decision-maker with alternative perspectives to help him orher figure out the best outcome. And in a culture that likely pres-elects for opinionated, self-assured personalities, Dalio warns againstarrogance. “Ask yourself whether you have earned the right to havean opinion,” he says.26 Such a right is earned through successful trackrecords and proven responsibility. Dalio compares this to skiing downa difficult slope; if you can’t successfully manage such a feat, youshouldn’t tell others how to do it.27 For their part, managers mustdistinguish between opinions that have the most merit – because theydraw on a person’s experience – and those that are merely conjecture.

Although a leader nearing the end of a successful career, Daliotempers the dangers of over-confidence by including among his own


most valued principles “the power of knowing how to deal with notknowing.”28 He attributes his success in part to having recognized andadhered to this principle, because its power has enabled him to askquestions, seek advice, and find the best answers to difficult questions.Surprisingly, this hard-driving financier shares a belief in not knowingwith a soft-spoken designer of women’s fashion, Eileen Fisher, whootherwise bears very little resemblance to Dalio.

Be a Don’t Knower

Eileen Fisher is among those leaders who calls herself a “don’tknower.”29 She began her now-celebrated clothing brand in 1984,at the age of 34, when she did not know how to sew and knewlittle about either fashion or business. Today, as a leader, Fishermodels vulnerability and humility, which unsurprisingly helps tocreate psychological safety in the workplace, as we will explorefurther in Chapter 7. She speaks honestly about her struggles andfears. Painfully shy when she was younger, she was afraid to go intoBloomingdale’s with her first clothing designs because she was afraidof being rejected. Inspired by the kimonos she’d seen while workingas a graphic designer in Japan and with access to one friend’s boothat the Boutique Show – a kind of arts and crafts fair – and anotherfriend’s skill with a sewing machine, Fisher launched her companyby designing first four and then eight pieces of clothing for theborrowed booth. On the first go-around she received orders frombuyers for $3000, and for the second show, she was surprised to findbuyers lining up to orders totaling $40 000.30

Today, Eileen Fisher, the company, operates nearly 70 retailstores, which generated between $400 and $500 million in revenuein 2016.31 It’s a supplier to many other clothing retailers and hasconsistently been recognized as one of the best companies to workfor. Unlike the businesses featured in Chapter 3 that faced enormousfailures, the company has enjoyed continuous growth and thoughtful,productive change, unblemished by financial, legal, or safety failures.


Its management practices and governance structures have created ashowcase for psychological safety.

Humble Listening

Fisher calls herself a natural listener, which helps to make “not know-ing” a positive trait. When first setting up her company, she foundthe combination of these two traits to be an advantage. As she says,“when you don’t know and you’re really listening intently, peoplewant to help you. They want to share.”32 Evidently, she’s managedto maintain the vulnerability and receptivity of her original “I don’tknow,” even as she’s become a seasoned leader of an enduring brandin the fashion industry. One of the outcomes of managing by notknowing is, as Fisher says, that “people feel safe to explore their ownideas instead of feeling like they just need to do what you tell themto do.”33

Eileen Fisher clothing is structured along simple lines andfluid designs. The same could be said for the way the companyconducts its meetings. People sit in a circle, with the intention ofde-emphasizing hierarchies and instead encouraging what’s called“a leader in every chair.”34 To create the mindfulness and focusconducive to an environment where everyone collaborates andcontributes, meetings begin with a minute of silence. Sometimes anobject, such as a gourd, is passed from person to person; the ideais the person is allowed and expected to speak when the object isin hand.35 The point is that Fisher, like the other leaders discussedin this chapter, has institutionalized very specific processes that helpcreate psychological safety.

Among the things that Fisher does know is what it’s like to feelunsafe to speak up. In school she felt that speaking up meant riskingcriticism, humiliation, and embarrassment; consequently, it was, shefelt, “safer to say nothing than to figure out what you think and whatyou want to say.”36 Perhaps that’s partly why she’s so consciously andcarefully created an environment where employees feel safe speaking


their minds. Fisher, again: “My inclination is to ask questions, to getthe right people in the conversation and let everyone have a voice.The collective and collaborative process produces a lot of energy – it’sthe source of creativity and innovation.”37 Interestingly, Fisher, as aclothing designer, is not looking for “right answers” but for the mul-tiplicity of voices that produce a collaborative process and creativeenergy. She’s framing success as a certain kind of energy rather thanan immediate result.

Permission to Care

When Fisher describes how projects and initiatives come about in herorganization, she emphasizes encouraging employees to be passion-ate and giving them “permission to care.”38 For example, an assistant,Amy Hall, rose in the company to become Director of Social Con-sciousness by following her passion for how the company was runningits factories and treating its factory workers, eventually becominginvolved in setting standards for how factories operate worldwide.In 2013, at a four-day off-site company sustainability conference, thestaff made a commitment to produce only environmentally sustain-able clothing by the year 2020. Although the idea had not originallycome from Fisher, she wanted to lend her support and realized theimportance of simply saying, “yes.” Although she doesn’t call herselfa CEO, she realized that “saying yes gives people permission” to goforward.39

Like any company, Eileen Fisher has had to change and grow.Fisher rejected offers to become a public company, as well as an offerto sell to Liz Claiborne, a larger women’s clothing company, becauseshe didn’t feel that they were passionate enough about her company’sclothing and vision. Instead, in 2005, Fisher decided to pass part of thecompany ownership to her employees. In 2009, the brand underwenta major change in its marketing and product lines to appeal to youngerwomen in addition to the loyal customer base that had aged alongwith Fisher. More recently, Fisher sees empowering women and girls


as part of the company mission, and to that end she has foundedthe Eileen Fisher Leadership Institute. The company also gives grantsto women entrepreneurs and to nonprofits that foster leadership inwomen and girls.40

As it turns out, Fisher does know. As she says, “I’ve learned overtime that I actually have a lot to say, particularly around issues likesustainability and business as a movement. My voice matters.”41 Itmay be that Fisher herself is the last to know the strength of her ownvoice. For as the president of Macy’s North, Frank Gazetta, said aboutthe seasonal product lines with which he stocks his stores, “the voiceof Eileen is always there.”42

Ultimately, Eileen’s voice has been widely heard (and seen) inthe fashion industry because she was willing to take risks, willingto fail. In any creative industry, failure is a fact of life. Most designideas never come to fruition. Similarly, most film footage hits thecutting room floor, and many financial bets will fail before you hit awinner. Indeed, more and more people in leading companies aroundthe world are embracing the notion of failing well to succeed sooner.But as appealing and logical as the idea of learning from failure maybe, the truth is no one really wants to fail.

When Failure Works

A team of smart, motivated people in Palo Alto had worked for twofull years on an innovation project. The goal was to develop a processto turn seawater into an affordable fuel. You might think achievingsuch a goal would be impossible. But, scientists had already figuredout the necessary technology to make it work in very small quantities.The challenge for Project Foghorn, as the endeavor was called, wasto assess if the process could be commercially viable on a massivescale. After two years of hard work, however, the team reluctantlyadmitted that it could not get production costs low enough to producean economically competitive fuel, especially since by then the priceof oil had fallen. They decided to terminate the project.


Was the team fired? Humiliated? Did team members hang theirheads for weeks? Far from it. Every member of the Foghorn teamreceived a bonus from the company.43

Make It Safe to Fail

The company was Google X, an invention and innovation labthat operates as an independent entity within Google’s parentcompany, Alphabet. The mission of X, as it’s come to be called,is to launch “moonshot” technologies that will make the world abetter place.44 The explicit goal is to develop and commercializeradical, world-changing solutions to big problems, to produce thekind of breakthroughs that could eventually become as big as thenext Google.45 Intelligent failure is especially integral to success atX, and for this reason we can learn a lot about what makes it workand the mindsets that leaders encourage to make failure acceptablein their organizations.

Although the idea of rewarding people for failing may seem tocreate a problematic incentive, if we look closely enough we cansee its business logic, especially for a research organization that pur-sues big, audacious ideas. Astro Teller, CEO at X – or “Captain ofMoonshots,” to be precise – believes that it’s a superior economicstrategy to reward people for killing unpromising projects than it isto let unworkable ideas languish in purgatory for years and soak upresources.46 In other words, you have to fail at many attempts beforecoming up with a success. X considers over 100 ideas for moonshotseach year, in areas ranging from clean energy to sustainable farming toartificial intelligence. However, only a handful of these ideas becomeprojects with full-time staff working on them.47

Teller explained in his 2016 TED talk why and how X “make[s]it safe to fail.”

You cannot yell at people and force them to fail fast. People resist. Theyworry. “What will happen to me if I fail? Will people laugh at me?


Will I be fired? . . . The only way to get people to work on big, riskythings – audacious ideas – and have them run at all the hardest parts ofthe problem first is if you make that the path of least resistance for them.We work hard at X to make it safe to fail. Teams kill their ideas as soonas the evidence is on the table because they’re rewarded for it. They getapplause from their peers. Hugs and high fives from their manager, mein particular. They get promoted for it. We have bonused every singleperson on teams that ended their projects, from teams as small as two toteams of more than 30.48

Teller highlights how unpleasant it feels for us to fail, especiallyat work. It’s natural to worry what other people will think and aboutlosing our job. That’s why, unless a leader expressly and actively makesit psychologically safe to do so, people will seek to avoid failure.

Rapid Evaluation

Just as vital as creating a psychologically safe environment forsmart failure is constructing a specific process for handling failure.Teller and X pursue the mission through a process of disciplinedexperimentation. Just as scientists seek to find evidence that rejectstheir hypotheses, the company seeks to find evidence that its mostoptimistic and idealistic ideas will not work so it can kill off theseideas sooner rather than later and move onto other ones.49 Projectproposals can come from anyone inside or outside the company.To make sure that X only works on the most promising ideas, thecompany has a “Rapid Evaluation” team that processes proposals,vets ideas, and promotes only those that seem achievable. This team,which consists of a combination of senior managers and inventors,first runs a pre-mortem, trying to come up with as many reasonsas possible why the idea could fail.50 “Rapid Eval,” as the team isknown, considers the problem’s scale, feasibility, and technologicalrisks. During this iterative stage, issues are questioned, changed, andrefined by engaging in candid conversation that’s not unlike Pixar’sBraintrust.


Very few ideas make it past this Rapid Eval stage.51 If an idea isdeemed promising, its team must develop a crude prototype, ideally ina few days. X has a “Design Kitchen” in one of its buildings equippedwith tools and materials to create such physical prototypes.52 If RapidEval is convinced by the prototype, it runs the idea by a second busi-ness group called “Foundry,” which asks, “Should this solution exist?Is there a business case to be made for the proposed solution? If wecan build it, will people actually use it?”

The company honors smart failures in other ways, too. Prototypesthat never made it past the Foundry stage, and thus were dropped, areshowcased in the Palo Alto office.53 Since November 2016, X hasheld an annual celebration to hear testimonials about failed projects.(Failed relationships and personal tragedies are also welcomed.) Failedprototypes are placed on a small altar, and people say a few wordsabout what the project meant to them. Employees feel that this ritualhelps remove some of the emotional baggage they still carry frominvesting themselves into something that never came to be.54

Failing to Fail Is the Real Failure

For X, then, failing is not taboo. In fact, as Teller told BBC Newsin 2014, “real failure is trying something, learning it doesn’t work,then continuing to do it anyway.”55 Real failure is defined as notlearning, or not taking enough risks to fall flat on your face. Teller andX embrace failure so much that they don’t talk about succeeding ontheir projects at all; instead, they speak of “failing to fail.”56 Successfulfailure is an art. It helps if you can fail at the right time and for theright reasons. In Chapter 7, we’ll see other ways organizations makeuse of and institutionalize failure.

Caring for Employees

The power of psychological safety is not reserved for creative indus-tries such as film, fashion, and cutting-edge technology. The global


equipment and engineering company Barry-Wehmiller demonstratesthat psychological safety brings immense rewards in a manufacturingsetting. These rewards come in both economic and human develop-ment forms.57

Founded in St. Louis in the mid-1880s as a machine manufac-turer for the brewing industry, Barry-Wehmiller today is a $3 billionorganization that employs 12 000 people at 100-plus locationsin 28 countries.58 In 2015, CEO Bob Chapman and co-authorRaj Sisodia published Everybody Matters: The Extraordinary Powerof Caring for Your People Like Family, a book whose title conciselydeclares the company’s mission to “measure success by the waywe touch the lives of people.” Caring for employees – “teammembers” in Barry-Wehmiller-speak – using tangible measures ofemployee well-being has proved to be a sure recipe for establishing apsychologically safe workplace where learning and growth thrive.

The Great Recession of 2007–2009 presented a dramatic oppor-tunity for Barry-Wehmiller to make good on its promise to care forpeople like family. When new equipment orders declined consider-ably and layoffs seemed inevitable, Chapman instead initiated a pro-gram of shared sacrifice. Following his principle that in a caring family“all the family members would absorb some pain so that no mem-ber of the family had to experience a dramatic loss,”59 there were nolayoffs. Instead, all employees, no matter their position, took a manda-tory unpaid furlough of four weeks at the time of their choosing.Cost-cutting in the form of shared sacrifice manifested in other waysas well. Chapman reduced his salary to $10 500, suspended executivebonuses, halted contributions to retirement accounts, and reducedtravel expenses. What was the result? Unions supported the program.Team members created a market to help each other; those who couldafford to take more than a month off voluntarily traded with thosewho could not. Barry-Wehmiller rallied from the economic down-turn relatively easily and by 2010 reported record financial results. Inother words, by continuing to make its team members feel safe andcared for during a crisis, the company created a win-win situation foreveryone.


Barry-Wehmiller has developed a rigorous and well-documentedapproach to systematizing its values and methods, which create psy-chological safety as a by-product. That may be because the companyhas flourished by acquiring poorly performing companies and turningthem profitable since the mid-1980s. The majority were companiesthat provided equipment and services to industries such as packagingor paper manufacturing. Each acquisition – as of this writing, thereare over 100 – has been another opportunity to articulate and developBarry-Wehmiller’s culture and vision.60

Its internal “Guiding Principles of Leadership” document, for-mulated with employee input, is meant to, among other things, createan environment of trust, meaning, and pride that celebrates and bringsout the best in each person.61 Shortly after the document was drafted,Chapman traveled to various units and sat down with small groups ofpeople to listen to their feelings about the Principles. He learnedthat trust – employees feeling trusted by management – was key, andthat time clocks, break bells, and locking inventory in cages inhibitedthat trust. Chapman describes immediately getting rid of what hecalls “trust-destroying and demeaning practices”62 inappropriate forresponsible adults. Listening sessions, as they are called, have sincebecome institutionalized times where team members are asked tospeak their minds.

Barry-Wehmiller University was founded in 2008 to impartthe company’s distinct leadership practices and vision. Instructorsare mostly recruited and trained from within the organization, areencouraged to impart insight rather than information, and make useof storytelling to share experiences and emotions. Chapman saysthe company’s practice is to “Treat people superbly and compensatethem fairly.”63 For example, when the company instituted health-care policies that included checks into employee well-being andhabits, which contributed to a 5% reduction in healthcare costs forBarry-Wehmiller, team members were given a free month on payingtheir premiums.

Because most of their work involves the repetitive but intricateprocess-laden work that’s germane to assembly factories – see


Chapter 7 for more about the implications of different types of workfor psychological safety and learning – process improvements or theiropposite (stuck processes) have enormous consequences for perfor-mance. No one wants to institute changes to workplace processesthat make a job more difficult and create employee resentment,but too often memos handed down from the top do just that. Farmore reasonable is to have the people who are actually doing thework design and redesign the process. In the fearless organization,suggestions for improvement (kaizen) are actively recruited andinstituted when apt.

Asking for Input

Bob Chapman tells the story of setting up a machine shop in GreenBay, Wisconsin. Ten divisional presidents first spent a week on how toimprove the process of getting spare parts orders entered, completed,and shipped to customers. Analyses were run and reports generated,only to realize that the plan wasn’t going to work in practice. Anotherleadership team met, spent another week analyzing and projecting,this time also looking at how manufacturing space might be laidout. Still, no one felt confident enough to proceed. Finally, a thirdimprovement event was held, this time with two senior leaders andten people who were actually going to do the work: forklift drivers,assemblers, pickers, packers, and clerical staff. Now, suddenly, the wayforward was clear. In Chapman’s telling:

They [the workers] took cardboard cutouts onto the floor of the factoryand measured what they would need to bring different carts and forkliftsthrough. They could see the different clearance issues and recognized thatwork from one area often flowed to another. Lighter parts would be easierto carry a farther distance. They looked at how many steps it took, howsafe it was to have a forklift in an area, or whether it could come aroundthe outside in a safer configuration.64


This is a prime example of asking people for input and of thebenefits of doing so. Even better than to, for example, open an onlineportal to invite employee suggestions is to invite the responsible par-ties to the meeting! In Dalio’s terms, it’s the forklift operators them-selves who have earned the “right to have an opinion” on whetheror not there’s enough clearance for their trucks to pass through anarea. Contrast Barry-Wehmiller’s approach with the factory fellowfrom Chapter 2 who had an idea for improvement and could pointto no good reason for not offering it up. Had he been given a seat atthe table, chances are that management could have benefitted fromhis idea.

Chapman reports that the solution the assembly workers devisedwas still in place five years later. They were, he says, “able to share toimprove the process and create a meaningful, lasting, and more humanprocess for everybody in that organization.”65 What’s important tonote is just how much it can take on the part of everyone involved tocreate a fearless organization. Top management had to spend consid-erable time and have the good sense to recognize that its ideas wouldnot succeed. Factory workers had to be explicitly involved in theprocess of designing process. I don’t mean to imply that working ina fearless organization takes more effort or a tremendously difficultundertaking. It doesn’t. But initially, when we’ve been entrenchedin fear and its attendant mental frameworks, it’s not always obvious.Barry-Wehmiller leaders are superb practitioners of an essential psy-chological safety building practice I call Inviting Participation, to bediscussed in Chapter 7.

Learning from Psychologically Safe WorkEnvironments

Barry Wehmiller, Google X, Eileen Fisher, Bridgewater, and Pixarhave little in common on the surface. Yet they have managed to create


work environments characterized by unusual levels of candor, engage-ment, collaboration, and risk-taking, all of which have contributedto the creation of successful businesses – in strikingly varied ways.Chapter 6 highlights a few other unusual organizations and leaders.But this time our focus will be on efforts to promote or improvehuman health, dignity, or safety.

Chapter 5 Takeaways

◾ Workplaces characterized by candor can offer immense benefitsfor creativity, learning, and innovation.

◾ Leaders who are willing to say “I don’t know” play a sur-prisingly powerful role in engaging the hearts and minds ofemployees.

◾ Creating an environment that values employees yields benefitsin engagement, problem solving, and performance.

Endnotes

1. Franklin Delano Roosevelt. Presidential Inaugural Address. History.March 4, 1933. https://www.history.com/speeches/franklin-d-roosevelts-first-inaugural-address Accessed June 7, 2018

2. “Our Story.” Pixar Animation Studios, https://www.pixar.com/our-story-1#our-story Accessed June 7, 2018.

3. Catmull, E. & Wallace, A. Creativity, Inc.: Overcoming the Unseen ForcesThat Stand in the Way of True Inspiration. New York: Random House,2013. Print.

4. Catmull, E. & Wallace, A. 2013: 90.5. Catmull, E. & Wallace, A. 2013: 95.6. Catmull, E. & Wallace, A. 2013: 105.7. Barnes, B. “John Lasseter, a Pixar Founder, Takes Leave After ‘Mis-

steps.’” The New York Times, January 20, 2018. https://www.nytimes.com/2017/11/21/business/media/john-lasseter-pixar-disney-leave.html Accessed July 25, 2018.

8. Finkel, J. “Tales From the Crit: For Art Students, May Is the CruelestMonth.” The New York Times. April 30, 2006. https://www.nytimes

https://www.history.com/speeches/franklin-d-roosevelts-first-inaugural-address

https://www.history.com/speeches/franklin-d-roosevelts-first-inaugural-address

https://www.pixar.com/our-story-1#our-story

https://www.pixar.com/our-story-1#our-story

https://www.nytimes.com/2017/11/21/business/media/john-lasseter-pixar-disney-leave.html



https://www.nytimes.com/2006/04/30/arts/design/tales-from-the-crit-for-art-students-may-is-the-cruelest-month.html


.com/2006/04/30/arts/design/tales-from-the-crit-for-art-students-may-is-the-cruelest-month.html Accessed June 13, 2018.

9. For more on art crits, see http://bushwickartcritgroup.com/.10. Catmull, E. & Wallace, A. 2013. 10911. Catmull, E. & Wallace, A. 2013: 111.12. Catmull, E. & Wallace, A. 2013: 108–109.13. Catmull, E. & Wallace, A. 2013: 109.14. Catmull, E. & Wallace, A. 2013: 123.15. Dalio, R. “How to Build a Company Where the Best Ideas Win.”

TED. 2017. https://www.ted.com/talks/ray_dalio_how_to_build_a_company_where_the_best_ideas_win Accessed June 12, 2018.

16. Dalio, R. “Principles.” Ray Dalio. 2011. https://docs.google.com/viewer?a=v&pid=sites&srcid=ZGVmYXVsdGRvbWFpbnxlYm9va3Nkb3dubG9hZG5vdzIwMTZ8Z3g6MjY3NGU2Njk5N2QxNjViMgAccessed June 13, 2018.

17. Dalio, R. Principles, Vol. 1: Life & Work. New York: Simon & Schuster,2017. Print.

18. Dalio, R. 2011: 88.19. Ibid.20. Dalio, R. 2011: 89.21. Dalio, R. 2011: 17.22. Dalio, R. 2011: 88.23. Dalio, R. 2011: 19.24. Dalio, R. 2011: 96.25. Dalio, R. 2011: 105.26. Dalio, R. 2011: 102.27. Dalio, R. 2011: 190.28. Dalio, R. 2011: 189.29. Tenney, M. “Be a Don’t Knower: One of Eileen Fisher’s Secrets

to Success.” The Huffington Post. May 15, 2015. https://www.huffingtonpost.com/matt-tenney/be-a-dont-knower-one-of-e_b_7242468.html Accessed June 12, 2018.

30. Malcolm, J. “Nobody’s Looking At You: Eileen Fisher and the artof understatement.” The New Yorker. September 23, 2013. https://www.newyorker.com/magazine/2013/09/23/nobodys-looking-at-you Accessed June 12, 2018.

31. Fernandez, C. “Eileen Fisher Makes Strides Towards CircularityWith ‘Tiny Factory.’” The Business of Fashion. December 6, 2017.https://www.businessoffashion.com/articles/intelligence/eileen-fisher-makes-strides-towards-circularity-with-tiny-factory AccessedJune 8, 2018.



http://bushwickartcritgroup.com

https://www.ted.com/talks/ray_dalio_how_to_build_a_company_where_the_best_ideas_win

https://www.ted.com/talks/ray_dalio_how_to_build_a_company_where_the_best_ideas_win

https://docs.google.com/viewer?a=v&pid=sites&srcid=ZGVmYXVsdGRvbWFpbnxlYm9va3Nkb3dubG9hZG5vdzIwMTZ8Z3g6MjY3NGU2Njk5N2QxNjViMg

https://www.huffingtonpost.com/matt-tenney/be-a-dont-knower-one-of-e_b_7242468.html



https://www.newyorker.com/magazine/2013/09/23/nobodys-looking-at-you



https://www.businessoffashion.com/articles/intelligence/eileen-fisher-makes-strides-towards-circularity-with-tiny-factory

https://www.businessoffashion.com/articles/intelligence/eileen-fisher-makes-strides-towards-circularity-with-tiny-factory

http://bushwickartcritgroup.com/

https://docs.google.com/viewer?a=v&pid=sites&srcid=ZGVmYXVsdGRvbWFpbnxlYm9va3Nkb3dubG9hZG5vdzIwMTZ8Z3g6MjY3NGU2Njk5N2QxNjViMg


32. Tenney, M. May 15, 2015, op cit.33. Ibid.34. According to Janet Malcolm, Fisher subscribes to the philosophy artic-

ulated in a 2010 book called The Circle Way: A Leader in Every Chairby Ann Linnea and Christina Baldwin (published by Barret-Koehler)which posits circle leadership as both a paradigm shift for group col-laboration and a practice that draws upon the circle “lineage” derivedfrom cultures, such as Native American and Aboriginal.

35. Malcolm, J. September 23, 2013, op cit.36. Ibid.37. Dunbar, M.F. “Designer Eileen Fisher on how Finding Purpose

Changed Her Company. Conscious Company Media. July 4, 2015.https://consciouscompanymedia.com/sustainable-business/designer-eileen-fisher-on-how-finding-purpose-changed-her-company/Accessed June 8, 2018.

38. Ibid.39. Ibid.40. “Business as a Movement.” Eileen Fisher. https://www.eileenfisher

.com/business-as-a-movement/business-as-a-movement AccessedJune 8, 2018.

41. “Eileen Fisher, No Excuses.” A Green Beauty. December 7, 2016.https://agreenbeauty.com/fashion/eileen-fisher-no-excuses AccessedJune 8, 2018.

42. Beckett, W. “Eileen Fisher: A Pocket of Prosperity.” Women’s WearDaily. October 17, 2007.

43. Thompson, D. “Google X and the Science of Radical Creativity.” TheAtlantic. November 2017. https://www.theatlantic.com/magazine/archive/2017/11/x-google-moonshot-factory/540648/ Accessed June8, 2018.

44. “What We Do.” X. https://x.company/about/ Accessed June 8, 2018.45. Thompson, D. November, 2017, op cit.46. Ibid.47. Ibid.48. Teller, A. “The Unexpected Benefit of Celebrating Failure.” TED.

2016. https://www.ted.com/talks/astro_teller_the_unexpected_benefit_of_celebrating_failure Accessed June 8, 2018.

49. “Celebrating Failure Fuels Moonshots.” Stanford ECorner, April 20,2016. https://ecorner.stanford.edu/podcast/celebrating-failure-fuels-moonshots/ Accessed June 8, 2018.

50. Thompson, D. November 2017, op cit.

https://consciouscompanymedia.com/sustainable-business/designer-eileen-fisher-on-how-finding-purpose-changed-her-company

https://consciouscompanymedia.com/sustainable-business/designer-eileen-fisher-on-how-finding-purpose-changed-her-company

https://www.eileenfisher.com/business-as-a-movement/business-as-a-movement

https://www.eileenfisher.com/business-as-a-movement/business-as-a-movement

https://agreenbeauty.com/fashion/eileen-fisher-no-excuses

https://www.theatlantic.com/magazine/archive/2017/11/x-google-moonshot-factory/540648

https://www.theatlantic.com/magazine/archive/2017/11/x-google-moonshot-factory/540648

https://x.company/about

https://www.ted.com/talks/astro_teller_the_unexpected_benefit_of_celebrating_failure

https://ecorner.stanford.edu/podcast/celebrating-failure-fuels-moonshots

https://ecorner.stanford.edu/podcast/celebrating-failure-fuels-moonshots

https://www.ted.com/talks/astro_teller_the_unexpected_benefit_



51. Gertner, J. “The Truth About Google X: An Exclusive LookBehind The Secretive Lab’s Closed Doors.” Fast Company. April 15,2014. https://www.fastcompany.com/3028156/the-google-x-factorAccessed June 13, 2018.

52. Ibid.53. Thompson, D. November 2017, op cit.54. Ibid.55. Wakefield, D. “Google boss on why it is OK to fail.” BBC News.

February 16, 2016. http://www.bbc.com/news/technology-35589220 Accessed June 14, 2018.

56. Dougherty, C. “They Promised Us Jet Packs. They Promised theBosses Profit.” The New York Times. July 23, 2016. https://www.nytimes.com/2016/07/24/technology/they-promised-us-jet-packs-they-promised-the-bosses-profit.html Accessed June 14, 2018.

57. Information on Bob Chapman and Barry-Wehmiller comes fromChapman’s book Everybody Matters and a case study conducted by myHBS colleague Jan Rivkin:◾ Chapman, B. & Sisodia, R. Everybody Matters: The Extraordinary

Power of Caring for Your People Like Family. US: Penguin-RandomHouse, 2015. Print.

◾ Minor, D. & Rivkin, J. Truly Human Leadership at Barry-Wehmiller.Case Study. HBS No. 717-420. Boston, MA: Harvard BusinessSchool Publishing, 2016.

58. “Surpassing 100 acquisitions, Barry-Wehmiller looks to the future.”Barry-Wehmiller. February 6, 2016. https://www.barrywehmiller.com/docs/default-source/pressroom-library/pr_bw_100acquisitions_020618_final.pdf?sfvrsn=2 Accessed June 8, 2018.

59. Chapman, B. & Sisodia, R. 2015: 101.60. “Surpassing 100 acquisitions, Barry-Wehmiller looks to the future.”

February 6, 2016, op cit.61. Chapman, B. & Sisodia, R. 2015: 53.62. Chapman, B. & Sisodia, R. 2015: 59.63. Chapman, B. & Sisodia, R. 2015: 53.64. Chapman, B. & Sisodia, R. 2015: 17065. Ibid.

https://www.fastcompany.com/3028156/the-google-x-factor

http://www.bbc.com/news/technology-35589220

http://www.bbc.com/news/technology-35589220

https://www.nytimes.com/2016/07/24/technology/they-promised-us-jet-packs-they-promised-the-bosses-profit.html



https://www.barrywehmiller.com/docs/default-source/pressroom-library/pr_bw_100acquisitions_020618_final.pdf?sfvrsn=2



6Safe and Sound

“It is not death that a man should fear, but he should fear never beginning to live.”—Marcus Aurelius1

“Birds,” said Captain Chesley “Sully” Sullenberger III.“Whoa,” said First Officer Jeffrey Skiles.The two pilots, side by side nearly three thousand feet above

Manhattan on a cold, clear day in January 2009, both knew that thisdeceptively simple word – birds – could spell disaster. Sullenberger,age 57, and Skiles, age 49, had met for the first time just hours earlier.Both were highly-experienced pilots, well-versed in the clippedverbal exchanges of cockpit communications.2 For the next fewseconds they watched as Canadian geese filled the windscreen, hearda loud thudding as the large birds were ingested into the Airbus’engines, and then smelled burning feathers and flesh. The lives of150 passengers and five crew, including their own, would depend onhow the two pilots, the crew, and the air traffic controller handled thenext three minutes. What would become a miraculous, zero-fatality

129


landing on the Hudson River drew on aviation training, navigationskills, old-fashioned luck, and that extra, less tangible quality thatknowledge workers today must acquire: the ability to team bycommunicating fearlessly. Fearless communication is vital input intomaking complex decisions, often quickly, that have no precedentand bring serious consequences.

Use Your Words

We have many examples of how even brief verbal exchanges canbe thwarted by a lack of psychological safety. The nurse who hes-itates to speak up to a surgeon about a possible procedural errorbecause past exchanges led her to think this would bother him; thenew engineer on a project who doesn’t ask a question because shefears looking stupid; and the boss who doesn’t listen to ideas fromemployees because he thinks it will make him appear weak. We havefewer examples of the nuanced exchanges that occur in situationsof high psychological safety, especially those with high stress, and ofthe positive outcomes that ensue. But those excruciating few minutesof cockpit conversation, recorded that January afternoon, are worthdeconstructing. Each of the small team of key participants felt safeenough with one another to become heroes together.

The bird strike took place about 90 seconds after Flight 1549’stakeoff from New York City’s LaGuardia airport. The immediateproblem: dual engine failure. The next problem: dual engine fail-ure was classified as a “non-normal situation,” and was not includedin the automated systems that warn pilots of system failures and dis-play instructions on the monitor for handling the failure.3 In short,dual engine failure from bird strikes was exceedingly rare – borderingon unheard of. Airline policy asked captains “to use common senseand good judgment, especially in those situations not specifically cov-ered.”4 In other words, they were on their own.

Immediately, Sullenberger, or “Sully” as he has been immor-talized in the eponymous Hollywood film, who had been serving

Safe and Sound 131

as copilot, took over the controls from Skiles. “My aircraft,” saidSullenberger, using aviation coded shorthand, as he put his hands onthe controls.

Although almost instinctive, the decision was driven by good rea-soning: Sully had logged far more hours flying the A320 than hadSkiles. Perhaps most important, from where he sat, Sullenberger couldsee the cityscape and George Washington Bridge out his left viewingwindow, while Skiles could not. Also relevant: Skiles was the pilotwho was more familiar with emergency procedures and could thusbetter manage the landing equipment.

“Your aircraft,” replied Skiles.That was all it took. There was no hesitancy, fear, apology, or

disagreement from either man.Sullenberger had long played a major role in training other pilots

in Cockpit Resource Management (CRM) at US Airways.5 Passion-ately committed to the program, which emphasizes interpersonalcommunication, leadership, and decision-making under pressure, it’shard to imagine any pilot with a better understanding of the needfor crew members to feel able to speak up than Sully. Both he andSkiles felt they were operating in a psychologically safe environment.But the cockpit pilots were not the only members of that intenselyhigh-performing team that day.

Next, Sullenberger informed Patrick Harten, the air trafficcontroller who worked out of the large Long Island center thatcontrols arrivals and departures out of the greater New York area,that they’d hit birds and were turning back to LaGuardia. “Mayday,mayday, mayday,” said Sullenberger, citing the universal message forlife-threatening distress. Harten took the necessary measures, whichincluded calling the LaGuardia control tower to tell them to preparefor an emergency landing.

A Virtual Team in the Learning Zone

Meanwhile, Skiles was unsuccessful in his attempts to restart theengines, in part because the plane was not moving fast enough.


“We don’t have that,” he told Sullenberger, referring to the plane’sspeed. Sullenberger agreed, and then was silent. He was mentallycalculating whether they’d have a better chance trying to make it toan airport runway or to land on the river below. Although Hartentried several times to direct the Airbus toward a nearby airport fromthe control tower, each time Sullenberger replied that he was “un-able.” He then reported he would be taking the riskiest but, to him,most feasible option: landing in the Hudson River. It was also theoption that would minimize chances of harming bystanders on theground in the densely populated city below. Harten, dumbfoundedand believing landing in the water would almost certainly result inthe pilots’ deaths, asked Sullenberger to repeat his intention. Thiswas as much a trained reflex as a conscious request. As we saw in the1977 Tenerife disaster when a Royal Dutch Airlines (KLM) captainmisunderstood the instructions of an air traffic controller – who saidhe was not cleared for takeoff – and proceeded to speed down a foggyrunway and collide with another plane, the tiniest break in claritycan result in hundreds of needless deaths. Harten was well trained.

Soon – no more than a minute later – it was time for the cockpit toalert the rest of the flight crew and the passengers. Again, Sullenbergercommunicated deliberately and carefully in the way he thought mostlikely to achieve a good outcome. Afraid of how hard the plane mighthit the water, he chose not to tell the flight crew to prepare for awater landing – in which case he knew they would instruct passengersto don life jackets, consuming valuable time. Instead, he broadcast,“This is the captain. Brace for impact.” The three flight attendantsthen shouted at the passengers to put their heads down and grab theirlegs, as directed by emergency landing protocol. Sullenberger steeredthe airplane to a perfect, if unavoidably violent, landing, while Skilescalled out altitude and speed. Some passengers suffered injuries, mostrelatively minor, but not a single life was lost in this almost miraculousoutcome. Soon, nearby boats swarmed to area and rescued passengersbefore anyone suffered hypothermia.

Safe and Sound 133

Using Time Well

Let’s look more closely at what was accomplished here with very few,very precise words. Although clearly an extreme case, the humaninteractions in this extraordinary situation provide a compellingdemonstration that clarity and candor do not necessarily meangetting bogged down in endless discussions. Psychological safetydoes not imply excessive talking and over-processing. Psychologicallysafe meetings do not have to take longer. Conversely, I’ve studiedmanagement team meetings where low psychological safety gaverise to indirectness of argument that consumed far more time thannecessary. Worse, key decisions were often postponed due to evidentconflict that was not effectively discussed, making the discussionsand the total decision time (in months) take far more time thannecessary.6

Learning from Other Industries

What we can learn from this extreme case, as well as from many casesof normal business conversation, is that psychological safety must bepaired with discipline to achieve optimal results efficiently. Considerthat, for his part, Harten asked only essential questions; also, he keptthe phone lines open as he spoke to the other air controllers, so thatSullenberger could hear those conversations at the same time, againsaving valuable time because Harten did not have to repeat them. Sul-lenberger later wrote about Harten, “his words let me know that heunderstood that these hard choices were mine to make, and it wasn’tgoing to help if he tried to dictate a plan to me.”7 And then therewas what was not said. For many of those crucial seconds, Sullen-berger and Skiles silently concentrated on their respective tasks andkept an eye on each other for the visual clues that kept them workingas a coordinated team.


Flight 1549’s experienced flight crew was well trained in stan-dard aviation equipment protocols and procedures. Equally impor-tant, they were trained in threat and error management (TEM) andCRM (also sometimes called Crew Resource Management). Bothprograms teach ways of thinking and decision-making. CRM – aprogram that, among other skills, instructs aviation crews to speakup to their captain when they feel something is wrong and likewiseinstructs captains to listen to crew concerns – is especially well suitedto creating environments of psychological safety. CRM training, nowrequired for all pilots, was first begun in response to Tenerife andother similarly tragic accidents, such as the 1982 Air Florida fatallanding in the Potomac in which a copilot could not bring him-self to insist that the captain turn back in the face of freezing rainand incomplete de-icing, and the 2013 Asiana Airlines crash at theSan Francisco airport, when a copilot was afraid to warn his captainabout a low-speed landing.8

Training modeled after CRM has also spread to medical envi-ronments. The goal has been to increase patient safety by promotingbetter communication and teamwork.9 In one study, a CRM-liketraining in communication and teamwork was shown to produce bet-ter outcomes in the delivery room for both mothers and babies. Theprogram also led to greater patient and staff satisfaction.10

It can be tempting to discount the value of the Hudson Miraclein demonstrating psychological safety and teaming in action becauseof the role played by emergency protocols in shaping the response.However, as we have seen far too often in aviation, as well as in otherhighly-protocolized settings like the operating room, the existence ofprocedures does not ensure their use. Without psychological safety,micro-assessments of interpersonal risk tend to crowd out properresponses. We simply fail to recognize the implications of our hesi-tation or silence in the moments in which we could have spoken up.Psychological safety can thus be seen as a precondition for theeffective use of emergency protocols. But, as we will see in the nextcase, emergencies are not the only context where a psychologicallysafe work environment can foster human health and safety.

Safe and Sound 135

One for All and All for One

What does a leading provider of kidney dialysis services for 200 000patients around the world have in common with a nineteenth centuryhistorical novel?11 Answer: a swashbuckling hero who brandishes asword and lives by the motto “one for all and all for one.”

At DaVita Kidney Care, the swashbuckler is CEO and ChairmanKent Thiry.12 Thiry is known to leap about the stage brandishinga sword while wearing full musketeer regalia in front of hundredsof frontline employees – patient care technicians, nurses, and socialworkers – in attendance for the regularly offered two-day DaVitaAcademy program, one of the foundational seminars for new employ-ees put on by the DaVita University. Thiry’s unusual choice of personaand costume, along with frequent high-fives and other high-intensityinteractions, seem to reflect his comfort bringing his whole self tothe workplace, so as to signal to others that they can do so too.The program offers many team-building and socializing activities forattendees that include songs, skits, games, storytelling, refreshments,music, and dancing and is intended to introduce employees to theDaVita culture. Thiry also leads a town hall question and answersession, where he is willing to be vulnerable (often admitting, forexample, that he doesn’t know the answer to a question) and open,entertaining direct questions about wages and promotions. The “Onefor All and All for One” slogan conveys a company core value – theidea of shared obligations and responsibility. All Davita workers arecalled upon to contribute their best to the company; likewise, thecompany is responsible for helping individuals develop and succeed.Attendance at the Academy program is voluntary, but the company’sdata shows that people who do attend have a turnover rate of about12% compared to the 28% who do not attend.13

Hired in 1999 to rescue the company from the brink of ruin,Thiry is credited with having turned it around by building a set ofvalues and a culture that combine to create a high level of psycholog-ical safety. Much like Bob Chapman at Barry-Wehmiller, discussedin Chapter 5, Thiry believes in fostering a community where people


on every level of the organization have a voice and are developed asleaders. As part of giving people a voice, Thiry decided to involvethem in creating a list of core values, which were then voted on by600 of the company’s clinician-managers. Employees (called team-mates) were asked to vote to find the new name, DaVita, when Thirywanted to rename the company, previously called Total Renal Care.To help prepare frontline employees for their responsibilities as team-mates, and to support them in taking on administrative roles, DaVitaUniversity provides many leadership development programs, with anemphasis on management and team skills, along with programs onquality improvement.

Thiry refers to himself as the “mayor” of DaVita “village”and emphasizes that “building a successful company is a means tothe end of building a healthy community.”14 Also in support ofa healthy community, the DaVita Village Network fund exists tohelp teammates who may encounter unexpected medical expensesor have other financial difficulties. This is part of the “all for one”philosophy. The company matches donations teammates make intothe fund. Although the majority of teammates are low-skilled, hourlyworkers, DaVita offers comprehensive health and welfare benefits,including provisions for healthcare, retirement, tuition reimburse-ments, and, most surprisingly, stock options and profit sharing.These incentives help support Thiry’s demand that teammates cometo work “intending not only to do a solid day’s work, but also tostrive to make DaVita a special place.”15

Kidney dialysis patients, the majority of whom are suffering fromend-stage renal condition, are especially in need of the combinedefforts of a medical team that is “all for one.” Patients typicallyvisit a local clinic three to four times per week and are hookedup to the dialysis machine for about four hours at a time – forthe rest of what they know is likely to be a shortened life. Theymust endure the poke of needles and sit quietly while the machinedraws out and cleans the blood that their failed kidneys can nolonger process. They must adhere to a strict diet and often sufferfrom other chronic conditions, such as diabetes and heart disease.

Safe and Sound 137

Unsurprisingly, some become depressed, or worse, stop comingto the clinic for treatments, which leads soon to death. It’s emo-tionally difficult to care for dialysis patients. Up to 25% will dieeach year. Given these morale-lowering conditions, the excessivelyupbeat tone of the DaVita Academy sessions begins to makemore sense.

Most importantly, DaVita consistently delivers top clinical out-comes in its industry. That’s because good clinical outcomes in largepart depend on the quality of care delivered by the staff at the out-patient dialysis clinics where most patients are treated. Although atechnician’s job is ostensibly practical – to connect and disconnect thepatient to the machine and monitor the ongoing treatment – muchcan also depend on the relationships technicians establish with boththe patient and other caregivers. Patients who feel comfortable andtrusting – psychologically safe – with the clinic staff are more likelyto comply with a rigorous treatment plan. To encourage these pos-itive feelings, DaVita centers are often decorated with photographsof patients and their families, as well as by drawings made by them,their children, and their grandchildren. As one DaVita administra-tor said, “it’s important that the teammates like their jobs and smileand relate in a compassionate way to patients, because that makesthe patients feel better about being here.”16 In other words, clinicstaff who themselves feel supported by high levels of psychologicalsafety are able to support and bond with patients, which contributesto positive clinical outcomes.

As we have seen in other healthcare settings, speaking up and feel-ing psychologically safe enough to communicate across boundariesand well-established medical hierarchies also contributes to positiveclinical outcomes. In 2017, DaVita successfully participated in a pilotprogram run by the Centers for Medicare and Medicaid Services(CMS) to institute integrated care for dialysis patients – specificallyfor nurses, social workers, and technicians to communicate regu-larly with nephrologists about individual patients. As Roy Marcus,a medical director and participating nephrologist put it, “DaVita’sintegrated care team regularly communicates with nephrologists to


better address gaps in care that extend beyond dialysis. This frequentcommunication means I have the time and details I need to providebetter, more holistic care to my patients.”17

Kidney dialysis treatment is especially well suited to follow theInstitute for Healthcare Improvement’s triple aim for healthcare:improving patient experience, improving population health, andreducing cost per patient.18 Here, as in other industries, makingdramatic, systemic change happen is highly-dependent on buildingthe psychological safety that allows employees to speak up with theirconcerns and ideas for improvement, as well as to experiment insmall ways to figure out what works best.

Speaking Up for Worker Safety

By now you’re well aware that speaking up is easier said than done.There’s no switch to flip that will instantaneously turn an organizationaccustomed to silence and fear into one where people speak candidly.Instead, creating a psychologically safe workplace, as we’ll explore indepth in Chapter 7, requires a lot of effort to alter systems, structures,and processes. Ultimately, it means that deep-seated entrenched orga-nizational norms and attitudes must change. And it begins with whatI call “stage setting.” Let’s look at how Anglo American, one of theworld’s largest mines, headquartered in South Africa, prepared for andthen institutionalized speaking up.

When Cynthia Carroll was appointed in 2007, with much fan-fare, as the first female CEO of an international mining company,she was appalled by the number of worker fatalities been occurringin the company – nearly 200 in the 5 years prior to her arrival.19

Realizing that she was “in an unprecedented position to influencechange” as both an American/outsider in a foreign country and asa woman where “until very recently women hadn’t been allowed tovisit underground at mines in South Africa, let alone work there,”20

she immediately used her position to speak up and demand a policyof zero fatalities or serious injuries.

Safe and Sound 139

At first, others in the company, especially members of the oldguard who saw themselves as upholding tradition, refused to takeCarroll seriously. At least one executive responded by saying thatzero harm “will never happen in our lifetime.”21 Likewise, whenCarroll visited individual mines, the local managers tried to makeher understand that while safety was important, her demands wereunrealistic. Serious injuries and deaths were considered an inevitablehazard, part of mining’s dangerous physical demands. Furthermore itwas not uncommon to blame errors on the workers themselves. Theprevailing attitude in South Africa, according to Anglo American’schairman, Sir Mark Moody-Stuart, who was instrumental in hiringCarroll, was that workers who suffered injuries “took shortcuts, didnot always follow the rules; they were stupid.”22

Carroll’s response to the resistance could not have been moreunambiguous. She shut down one of the most problematic and dan-gerous mines. Rustenburg, located about 60 miles from Johannes-burg, was the world’s foremost supplier of platinum and generatedabout $8 million in revenue per day. Shutting down the mine wasboth bold and unprecedented. It immediately got everyone’s atten-tion. Even more shocking, Carroll insisted that before the mine couldrestart, she wanted to find out what the workers were thinking, andshe intended to get input from every single worker about how toimprove safety. This, she knew, was a direct challenge to Anglo Amer-ican’s strict hierarchical culture and rigid, top-down managementstyle, which had begun with the mine’s founding in 1917 and wasfurther strengthened by South Africa’s apartheid history.

Here’s where things get interesting. After shutting down themine, Anglo American executives gathered 3000 to 4000 workers ata time in a stadium and spoke about the importance of safety. Becausethe workers spoke a range of languages and literacy rates were low,the company used visuals to illustrate safety and hired a theater groupto role-play safety interactions between workers and supervisors.Employees were then divided into groups of 40 to 50 and asked tospeak up about their safety concerns and opinions. Understandably,the workers were reluctant to do so, having historically had no say.


As Carroll observed, “I wondered how much authority someonewho is underground for hours on end, with a shift supervisor rightbehind him, really has. I questioned whether a line worker had thepower to put up his hand and say, ‘I’m not going to do this, because itis unsafe.’”23 In other words, the workers had to feel psychologicallysafe in order to speak up about their physical safety.

Psychological safety had to be created in the mines by finding aculturally appropriate approach. With help from the unions, AngloAmerican leadership adopted a traditional South African method ofconducting village assemblies, called lekgotla. As you will see, lekgotlaseems to echo tenets and practices of psychological safety. Tradition-ally, in these assemblies (somewhat like meetings at Eileen Fisher),everyone sits in a circle and has a chance to speak without being inter-rupted or criticized; conversation continues for as long as it takes toreach consensus on whatever issue is at stake.24

During Anglo American’s lekgotla, senior managers reframed theinitial question. Instead of asking workers to give their opinionsdirectly about safety issues, they asked, “what do we need to do tocreate a work environment of care and respect?” That was whenworkers started to feel safe enough to speak up about specificconcerns. One group said that they’d like hot water at their worksite to clean up and make tea. (Management complied with thisrequest.) The dialogue continued until each group had developed acontract stating what specific actions were needed to maximize safety.In a powerful symbolic gesture of shared commitment, workersand Anglo American executives both signed the contract. As JudyNdlovu, an Anglo American executive said about this process, “thereal change was listening to the workers . . . Cynthia challengedmanagement to understand what the employees were thinking, whatthey felt when they went into the mine each day.”25 Previously, foran individual miner to speak up would have taken courage but mightvery well have been a foolish act if not well received by management.Once psychological safety started to take root in the culture, minerscould then speak up to help insure physical safety.

Safe and Sound 141

When the mines reopened, more than 30,000 workers wereretrained to comply with the newly agreed-upon safety protocols.Top leadership met with managers to discuss compliance with thenew rules and to emphasize that employees now had the right tostop work if safety standards were not being met. New policieswere instituted to insure regular review of safety procedures andto schedule times when management and executives continued tosolicit input from workers regarding safety operations. Guiding valueswere established. Executive meetings were now required to beginwith lengthy updates and discussions on safety. Although fatalitiesfell considerably – from 44 in 2006 to 17 in 2011, a reduction of62%26 – they did not reach zero. The company honored any workerwho died with memorial services and by posting their photographsin all buildings. The supervisor of the deceased visited the worker’sfamily and village to convey respect and sympathy. All these measureshelped to institutionalize not only the safety protocols but also apsychologically safe culture built by care and respect.

A year after the shutdown, Carroll chose to speak up yet again,this time to people outside the organization – the National Unionof Mineworkers and the Minister of Mines – to ask for their helpin working together to achieve zero harm. Again, she was rebuffed.However, in April 2008, a Safety Summit was held in Johannesburgbetween Anglo American, the South African Department of Min-erals and Energy, and the National Union of Mineworkers. It wasthe first time the three major stakeholders had come together. Aswith the mineworkers, it took time for representatives from the threegoverning entities to build trust and respect. The catalyst for work-ing together was the shared goal of dramatically improving physicalsafety in the mines. And process was instrumental. By visiting dif-ferent mines together and continuing to convene, the three groupsdeveloped a growing sense of respect and trust for one another. Thestakeholder partnerships that eventually developed helped spread ofthe passion for safety ignited at Anglo American into the rest of SouthAfrica’s mining industry.


Although production and revenues fell in the year following themine shutdown, in both 2008 and 2011, during Carroll’s tenure, thecompany achieved the highest operating profits in its history. Shareprice rose commensurably. Carroll realized that increasing physicalsafety in the mines was as much about transforming old attitudes aboutworker safety and changing the culture to make it safe to speak up asit was about technical or process improvements.

In previous chapters we saw how people up and down and acrossan organization can contribute to creating a climate of silence andfear. Similarly, people up and down and across the organization cancontribute to creating a climate of voice and safety. A leader can bethe driving force and catalyst for others to speak up; but ultimately,the practice must be co-created – and continuously nurtured – bymultiple stakeholders. As we have seen, commitment to doing this isparticularly vital for preventing or managing a crisis.

Transparency by Whiteboard

When people think of leadership in a crisis, all too often they thinkof someone like General George Patton, issuing decisive orders to hissoldiers and commandeering them to victory with toughness. Butthat isn’t always the case, especially when the enemy is technology ornatural forces, or both.

Let’s look at a less obvious example of heroic leadership in a crisis:Naohiro Masuda, the plant superintendent of the second Fukushimanuclear plant when the giant earthquake struck in March 2011. LikePatton, he inspired life-saving teamwork from his followers. However,Masuda did so by adhering to key principles that build psycholog-ical safety: honesty, vulnerability, communication, and informationsharing. And his key weapon was a whiteboard.

Fukushima Daini, less than five miles down the coast from itssister plant, Daiichi, also suffered severe damage from the earthquakeand tsunami waves.27 In stark contrast to Daiichi, however, Masudaand his 400 employees managed to safely shut down all 4 of the

Safe and Sound 143

plant’s reactors, thereby averting the ultimate disaster of releasingnuclear material into the air and sea. They managed to lay 5.5 milesof extremely heavy cable in 24 hours – a job that under normalcircumstances would take a team of 20, with machinery, at least amonth. And they worked for over 48 hours without sleep, in a stateof tremendous uncertainty, with fear for their lives and those of theirfamilies.

How did Masuda motivate his men to stay under such toughconditions? From the beginning, Masuda chose to issue informationrather than orders. After evacuating his workers to the EmergencyResponse Center (ERC), and having heard from operators in thecontrol rooms that three of the plant’s four reactors had lost all opera-tive cooling systems (the operators had bravely weathered the tsunamifrom their posts), Masuda knew the situation was “extremely seri-ous.”28 If the reactors could not be cooled, they would overheat,resulting in a nuclear breach.

Masuda and his team unfortunately lacked information about thephysical condition of the plant. They didn’t know what was brokenor what resources they might have. To find that out, workers wouldneed to venture outside to assess the damage and figure out whatcould be done to restore power to the reactors and stabilize the plant.And, for Masuda, that meant helping the workers – already shakenby earthquake and flood – feel psychologically safe enough to act.

Instead of grabbing a megaphone or commanding his men intoaction, Masuda began writing things down on a whiteboard: the mag-nitude and frequency of the earthquake’s aftershocks, calculations, anda rough chart that demonstrated the decreasing danger of the quakesover time. In other words, he armed his men with data. “I was notsure if my team would go to the field if I asked, and if it was evensafe to dispatch people there,” Masuda later reflected.29 Indeed, heallowed the men to make their own decisions about whether theywanted to assist in what might be a dangerous mission. At 10 p.m.,when Masuda finally asked the men to pick 4 groups of 10 workersto go out and survey the damage at each of the 4 reactors, not a singleone refused.


Having begun his career at Daini in 1982, when it was still underconstruction, Masuda was intimately acquainted with the plant. Thatknowledge allowed him to give each group detailed instructions aboutwhere to go and what to do. Concerned that fear might interfere withworkers’ ability to remember his instructions, he made the groupsrepeat the instructions back to him before they left. The point wasnot to command action but to assist them in acting quickly shouldthe situation change, and their safety be compromised.

By 2 a.m. on March 12, all 40 workers had safely returned to theERC with information. One of the reconnaissance teams reported acrucial break of good luck: there was still power inside the radiationwaste building behind Reactor 1. That meant the men could poten-tially get power to the cooling systems. But they would need to layheavy-duty cables – and a lot of them.

By dawn, Masuda and his team had drawn up a route to run cablesfrom the building down to the reactor units by the water. However,team leaders calculated that they lacked sufficient supplies to do thejob. Masuda, in turn, quickly contacted TEPCO headquarters and theJapanese government to request additional supplies and the calculated50 spools of cables.

While the men waited for the cables to arrive – which would notbe until the morning of March 13 – they learned about the explosionat Daiichi. Some were in disbelief. Many were afraid. Could the samething happen at Daini? Might they be endangering themselves bysticking around? Masuda addressed the 500–600 people in the room:“Please, trust me,” he said. “I definitely won’t do anything to harmyou, but Fukushima Daini is still in trouble, and I need you to doyour best.”30

When the cables finally arrived, the men immediately got to worklaying them from the waste building to the reactor units down by thewater. They began with Reactor 2, because it was at greatest risk ofoverheating. To power the three disabled reactors, the men wouldneed to lay almost 9 kilometers (5.5 miles) of cable. Each piece ofcable was 200 meters long and weighed about a ton. The opera-tors calculated they had only about 24 hours to perform a job that

Safe and Sound 145

under normal circumstances would take a month or more. And so,200 workers began frantically laying cables. Working in shifts, theymade agonizingly slow progress. It took about 100 workers to moveeach piece.

As the men raced against the clock, Masuda slowly came to anunwelcome realization: his plan was untenable. Even at the super-human pace the men were working, they would not have enoughtime to hook up all three reactors. The waste building was just toofar away.

Masuda’s strength as a leader was demonstrated by the immedi-ate admission of his mistake. In keeping with Ray Dalio’s Principles,Masuda succeeded by virtue of extreme candor – by telling peoplethe worst news, which he believed would increase the chances theycould figure out how to handle the situation. Despite its unwelcomenature, the admission increased the psychological safety in the teamand bonded the group more tightly. Consulting with his team leaders,Masuda concluded that they had no choice but to gamble by utilizingsome of the power from the generator of the lone functioning reac-tor unit. On the whiteboard, Masuda added in adjustments to theoriginal plan.

The men continued to work tirelessly throughout the day. Yet, asnight approached, some engineers noticed that the pressure in Unit 1was now climbing faster than that of Unit 2. Fortunately, they spokeup to inform Masuda that they now believed Unit 1 to be most vul-nerable and suggested to him that the workers refocus their energy.Equally important, Masuda listened closely to his engineers and tooktheir suggestions seriously.

Having seen his team push onward, without having slept in almosttwo days, Masuda was understandably reluctant to tell them, “redoit! Shift from Unit 2 to Unit 1!” Still, he broke the news. Thoughsome were upset, a climate of psychological safety and a recogni-tion of what was at stake helped them to commit to the new courseof action.

Just before midnight, ecstatic applause broke out when theworkers finished laying the last of the cable. At 1:24 a.m., they were


notified that the cooling function had been restored to Unit 1 – withabout two hours to spare. On the morning of March 15, Masuda andhis team were notified that all reactors were finally in cold shutdown.Finally, they could rest.

Masuda influenced the workers to act, even as the ground shookbeneath their feet. Through his calmness, openness, and willingness toadmit his own fallibility as a leader, Masuda created the conditions forthe team to make sense of their surroundings, overcome fear, and solveproblems on the fly. Although their physical safety was in constantdanger, they felt psychologically safe, and this allowed them to cometogether, try things, fail, and regroup. In the many moments of fearfor their lives over the course of those days, interpersonal fear withinthe group was nearly nil. Masuda’s words and actions set the tone andreassured workers that they could – and must – save the plant.

Unleashing Talent

Reflecting on the more than 20 cases included in Part II of this bookhelps us understand both how challenging and how important it is tobuild psychological safety to ensure that the talent in an organizationis able to be put to good use to learn, innovate, and grow. Speakingup is not a natural act in hierarchies. It must be nurtured. When it’snot, the results can be catastrophic – for people and for the bottomline. But when it is nurtured, you can be certain that it is the productof deliberate, thoughtful effort.

Creating a psychologically safe workplace takes leadership. Lead-ership can be seen as a force that helps people and organizationsengage in unnatural acts like speaking up, taking smart risks, embrac-ing diverse views, and solving remarkably challenging problems. Andso the chapters that lie ahead in Part III are focused on what lead-ers can and must do to create psychological safety. They invite you toconsider, and perhaps try out, a variety of practices that can contributeto creating a fearless organization.

Safe and Sound 147

Chapter 6 Takeaways

◾ Clear, direct, candid communication is an important aspect ofreducing accidents.

◾ A compelling company purpose combined with caring leader-ship motivates people to go the extra mile to do what’s neededto ensure safe work practices and employee dignity.

◾ Worker safety starts with encouraging and reinforcing employ-ees’ speaking up about hazards and other concerns.

Endnotes

1. This quote is the popular version of a line written by the Stoic philoso-pher Marcus Aurelius in Book XII of his The Meditations: “ . . . if thoushalt be afraid not because thou must some time cease to live, but if thou shalt fearnever to have begun to live according to nature- then thou wilt be a man worthyof the universe which has produced thee.” You can find Book XII of TheMeditations, translated by George Long, for free here: http://classics.mit.edu/Antoninus/meditations.12.twelve.html. Accessed July 27, 2018.

2. Key details in the story of US Airways Flight 1549 described in thischapter come from the National Transportation Safety Board’s accidentreport, and from a series of published case studies:◾ National Transportation Safety Board. “Loss of Thrust in Both

Engines After Encountering a Flock of Birds and SubsequentDitching on the Hudson River, US Airways Flight 1549, AirbusA320-214, N106US, Weehawken, New Jersey, January 15, 2009.”

◾ Aircraft Accident Report NTSB/AAR-10/03. Washington, D.C.,2010;

◾ Howitt, A.M., Leonard, H.B., & Weeks, J. Miracle on the Hudson(A): Landing U.S. Airways Flight 1549. Case Study. HKS No. 1966.Cambridge, MA: HKS Case Program, 2012;

◾ Howitt, A.M., Leonard, H.B., & Weeks, J. Miracle on the Hudson(B): Rescuing Passengers and Raising the Plane. Case Study. HKSNo. 1967. Cambridge, MA: HKS Case Program, 2012;

http://classics.mit.edu/Antoninus/meditations.12.twelve.html

http://classics.mit.edu/Antoninus/meditations.12.twelve.html


◾ Howitt, A.M., Leonard, H.B., & Weeks, J. Miracle on the Hudson(C): Epilogue. Case Study. HKS No. 1967.1. Cambridge, MA: HKSCase Program, 2012.

3. “Statement of Captain Marc Parisis, Vice President, Flight Operationsand Services, Airbus.” National Transportation Safety hearing. June 9,2009. Washington, DC. 80–82.

4. U.S. Airways FOM 1.3.4, Captains Authority, online at National Trans-portation Safety Board, Operations/Human Performance Group Chair-men, Exhibit No. 2-Q.

5. Sullenberger III, C. & Zaslow, Z. Highest Duty: My Search for What ReallyMatters. New York, NY: William Morrow, 2009.

6. Edmondson, A.C. “The Local and Variegated Nature of Learning inOrganizations: A Group-Level Perspective.” Organization Science, 13.2(2002): 128–46.

7. Sullenberger III, C. & Zaslow, Z. 2009: 229.8. Wheeler, M. “Asiana Airlines: ‘Sorry Captain, You’re Wrong.’” LinkedIn

Pulse. 2014. https://www.linkedin.com/pulse/20140217220032-266437464-asiana-airlines-sorry-captain-you-re-wrong/ AccessedJune 12, 2018.

9. See, for instance, Oriol, M.D. “Crew resource management: applica-tions in healthcare organizations.” Nursing Administration 36.9 (2006):402–6; McConaughey E. “Crew resource management in healthcare:the evolution of teamwork training and MedTeams.” Journal of PerinatalNeonatal Nursing, 22.2 (2008): 96–104.

10. Shea-Lewis, A. “Teamwork: crew resource management in a commu-nity hospital.” Journal of Healthcare Quality. 31.5 (2009): 14–18.

11. The Three Musketeers, written in 1844 by French author AlexandreDumas and set in 1625 France, has achieved popularity via its manyadaptations into film, video, and television.

12. Key details about DaVita and its CEO/lead musketeer Kent Thiry comefrom a series of case studies:◾ Pfeffer, J. Kent Thiry and DaVita: Leadership Challenges in

Building and Growing a Great Company. Case Study. Stanford GSBNo. 0B-54. Palo Alto, CA: Stanford Graduate School of Business,2006.

◾ O’Reilly, C. Pfeffer, J., Hoyt, D., & Drabkin, D. DaVita: ACommunity First, A Company Second. Case Study. Stanford GSBNo. OB-89. Palo Alto, CA: Stanford Graduate School of Business,2014.

https://www.linkedin.com/pulse/20140217220032-266437464-asiana-airlines-sorry-captain-you-re-wrong

https://www.linkedin.com/pulse/20140217220032-266437464-asiana-airlines-sorry-captain-you-re-wrong

Safe and Sound 149

◾ George, B., & Kindred, N. Kent Thiry: “Mayor” of DaVita. CaseStudy. HBS Case No. 410-065. Boston, MA: Harvard BusinessSchool Publishing, 2010.

13. Pfeffer, J. Kent Thiry and DaVita: Leadership Challenges in Buildingand Growing a Great Company. 2006: 19.

14. Pfeffer, J. Kent Thiry and DaVita: Leadership Challenges in Buildingand Growing a Great Company. 2006: 2.

15. Kent Thiry, presentation at the Stanford Graduate School of Business.November 17, 2011.

16. O’Reilly, C. et al. DaVita: A Community First, A Company Second.2014: 7.

17. “Integrated Care Enhances Clinical Outcomes for Dialysis Patients.”News-Medical.net. October 31, 2017. https://www.news-medical.net/news/20171031/Integrated-care-enhances-clinical-outcomes-for-dialysis-patients.aspx Accessed June 8, 2018.

18. Berwick, D.M., Nolan, T.W., & Whittington, J. “The Triple Aim: Care,Health, and Cost.” Health Affairs. 27.3 (2008): 759–69.

19. Key details describing the safety initiative at Anglo American underCynthia Carroll in this chapter come from a series of case studies byHBS Professor Gautam Mukunda and colleagues:◾ Mukunda, G., Mazzanti, L., & Sesia, A. Cynthia Carroll at Anglo

American (A). Case Study. HBS No. 414-019. Boston, MA: Har-vard Business School Publishing, 2013.

◾ Mukunda, G., Mazzanti, L., & Sesia, A. Cynthia Carroll at AngloAmerican (B). Case Study. HBS No. 414-020. Boston, MA: HarvardBusiness School Publishing, 2013.

◾ Mukunda, G., Mazzanti, L., & Sesia, A. Cynthia Carroll at AngloAmerican (C). Case Study. HBS No. 414-021. Boston, MA: Har-vard Business School Publishing, 2013.

20. Carroll, C. “The CEO of Anglo American on Getting Serious aboutSafety” Harvard Business Review. 2012. https://hbr.org/2012/06/the-ceo-of-anglo-american-on-getting-serious-about-safety AccessedJune 14, 2018.

21. Mukunda, G. et al. Cynthia Carroll at Anglo American (A). 2013: 7.22. Ibid.23. Carroll, C. 2012, op cit.24. De Liefde, W. Lekgotla: The Art of Leadership Through Dialogue.

Houghton, South Africa: Jacana Media, 2005.25. Mukunda, G. et al. Cynthia Carroll at Anglo American (B). 2013: 2.

http://news-medical.net

https://www.news-medical.net/news/20171031/Integrated-care-enhances-clinical-outcomes-for-dialysis-patients.aspx



https://hbr.org/2012/06/the-ceo-of-anglo-american-on-getting-serious-about-safety

https://hbr.org/2012/06/the-ceo-of-anglo-american-on-getting-serious-about-safety


26. Carroll, C. 2012, op cit.27. Key details on the close call at Fukushima Daini in this chapter come

from a spectacular episode of PBS’s NOVA from 2015, as well as aHarvard Business Review piece by my colleague Ranjay Gulati, whichdocumented Masuda’s leadership style:◾ O’Brien, M. (producer). “NOVA: Nuclear Meltdown Disaster.”

PBS, aired July 29, 2015. http://www.pbs.org/wgbh/nova/tech/nuclear-disaster.html Accessed June 15, 2018.

◾ Gulati, R., Casto, C., & Krontiris, C. “How the Other FukushimaPlant Survived.” Harvard Business Review, 2015. https://hbr.org/2014/07/how-the-other-fukushima-plant-survived Accessed June13, 2018.

28. O’Brien, M. (producer). July 29, 2015, op cit.29. Gulati, R. et al. 2015, op cit.30. Ibid.

http://www.pbs.org/wgbh/nova/tech/nuclear-disaster.html

http://www.pbs.org/wgbh/nova/tech/nuclear-disaster.html

https://hbr.org/2014/07/how-the-other-fukushima-plant-survived

https://hbr.org/2014/07/how-the-other-fukushima-plant-survived

PART

III Creating a FearlessOrganization

7Making it Happen

You can tell whether a man is clever by his answers. You can tell whether a man iswise by his questions.

—Naguib Mahfouz1

When Julie Morath came on board as chief operating officer atChildren’s Hospital and Clinics in Minneapolis, Minnesota, her goalwas simple: 100% patient safety for the hospitalized children underher care.2 The goal may have been simple. How to accomplish it wasnot. This was late 1999, and few people were talking about patientsafety. It’s not that most clinicians thought patients were completelysafe from mistakes and harm; it’s just that they tended to think thatwhen things went wrong, someone was to blame. This made it hardto talk about the problem. Nurses and doctors, Morath knew, firsthad to become willing to speak up to report errors if was going to bepossible to reduce the incidence of harm. In short, she needed the

153

154 Creating a Fearless Organization

data on what was happening, when, and where. Only then could thehospital find new ways to enhance the safety of all of the vulnerableyoung patients at their six medical facilities in the Twin Cities.

The Leader’s Tool Kit

In previous chapters, we saw how a lack of psychological safetystopped a NICU nurse from speaking up about a possible medi-cation error for fear of annoying the physician. We saw how well-trained clinicians at a cutting-edge medical facility failed to questiona fatal chemotherapy dosing regimen over a period of severaldays. These situations both took place in settings where a lot wasgoing on.

Tertiary care hospitals, like Children’s, are complex. It’s challeng-ing to get every single task done perfectly every single time. To beginwith, every patient is different. No two care episodes are identical.Upping the ante, the highly-interdependent work of patient care mustbe seamlessly coordinated among narrow specialists with complemen-tary knowledge and skills – who may not even know each other’snames. Multiple, interdependent departments – pharmacy, labora-tory, physicians, and nursing – who have conflicting priorities aboutwhat service to provide at what time must coordinate their actionsfor safe care to be consistently delivered. And so the organization hadlong accepted that things would occasionally go wrong. A certainnumber of slip-ups and crossed wires was just the way things were.It wasn’t discussed much, and there was an unfortunate tendencyto blame individuals (rather than system complexity) for errors thatslipped through the cracks and led to patient harm.

Morath felt that this attitude had to change if progress was to bemade. She needed a leadership tool kit to get this done. In retrospect,what happened to profoundly shift attitudes and behaviors at Chil-dren’s can be divided into three categories: setting the stage, invitingparticipation, and responding productively.

Making it Happen 155

Setting the Stage

As soon as she took the job, Morath began speaking to large andsmall groups in the hospital to explain that healthcare delivery, byits nature, was a complex system prone to breakdowns. She presentednew research and statistics on medical adverse events to educate every-one about their prevalence. She introduced new terminology (“wordsto work by”) that altered the meaning of events and actions in impor-tant ways; for instance, instead of an “investigation” into an adverseevent, the hospital would use the term “study;” instead of “error” shesuggested people use “accident” or “failure.” In subtle but importantways, Morath was trying to help people think differently about thework – and especially about what it means when things go wrong.These leadership actions comprise what I refer to as framing the work.

Frames consist of assumptions or beliefs that we layer onto reality.3

All of us frame objects and situations automatically. Our focus is on thesituation itself, and we are typically blind to the effects of our frames.Our prior experiences affect how we think and feel about what’spresently around us in subtle ways. We believe we’re seeing reality –seeing what is there. For instance, if we frame medical accidents asindications that someone screwed up, we will ignore or suppress themfor fear of being blamed or of pointing the finger at a colleague.However, we can shift our automatic frames and create a shared framethat more accurately represents reality. More information about fram-ing the work is provided later in this chapter. But when Morathbegan to give presentations that called attention to hospital care asa complex, error-prone system, what she was doing was framing thework – or, more accurately, reframing it. Her goal was to help peopleshift from a belief that incompetence (rather than system complexity)was to blame. This shift in perspective would prove essential to help-ing people feel safe speaking up about the problems, mistakes, andrisks they saw.4

In setting the stage for open discussion of error, Morath alsocommunicated urgency about the goal of 100% patient safety.


I consider this an important stage-setting act because it helpedpeople reconnect with the reasons they went into healthcare in thefirst place: to save lives. This reminder helped motivate people to dothe hard work of reporting, analyzing, and finding ways to preventharm. In short, with an emphasis on the complex and error-pronenature of the work, and a reminder of what was at stake (children’slives), Morath had set the stage for candor. But that was not enoughto make it happen.

Inviting Participation

As you may imagine, hardworking neonatal nurses and experiencedpediatric surgeons did not immediately flock to Morath’s office toconfess to having made or seen mistakes. People found it easier tobelieve that medical errors happened elsewhere rather than in theirown esteemed institution. Even if they understood, deep down, thatthings can and do go wrong, it was not front of mind, and they gen-uinely believed they were providing great care.

Morath, hearing silence from the staff, stopped to consider. I’msure it crossed her mind to try again – to re-explain the complex,error-prone nature of tertiary care hospital operations so as to correctthe staff’s implicit response that nothing was going wrong. If so, sheresisted the temptation to lecture. Instead, she did something that wasas simple as it was powerful. She asked a question. “Was everything assafe as you would like it to have been this week with your patients?”5

The question – genuine, curious, direct – was respectful and con-crete: “this week,” “your patients.” Its very wording conveys genuineinterest. Curiosity. It makes you think. Interestingly, she did not ask,“did you see lots of mistakes or harm?” Rather, she invited peopleto think in aspirational terms: “Was everything as safe as you wouldlike it to be?” Sure enough, psychological safety started to take hold.People began to bring up incidents that they had seen and even con-tributed to.


Morath enhanced her invitation to participate with several struc-tural interventions. First, she set up a core team called the PatientSafety Steering Committee (PSSC) to lead the change initiative. ThePSSC was designed as a cross-functional, multilevel group to ensurethat voices from all over the hospital would be heard. Each memberwas invited with a personal explanation for why his or her perspectivewas sought. Second, Morath and the PSSC introduced a new policycalled “blameless reporting” – a system inviting confidential reportsabout risks and failures people observed. Third, as people began tofeel safe enough to speak up, Morath led as many as 18 focus groups tomake it easy for people throughout the organization to share concernsand experiences.

These simple structures made speaking up easier. When you joina focus group, your input is explicitly requested. It feels more awk-ward to remain silent than to offer your thoughts. In this way, thevoice asymmetry described in Chapter 2, in which silence dominatesbecause of the inherent risks of voice, is mitigated.

Responding Productively

Speaking up is only the first step. The true test is how leaders respondwhen people actually do speak up. Stage setting and inviting partici-pation indeed build psychological safety. But if a boss responds withanger or disdain as soon as someone steps forward to speak up abouta problem, the safety will quickly evaporate. A productive responsemust be appreciative, respectful, and offer a path forward.

Consider the “focused event analysis” (FEA), a cross-disciplinarymeeting that Morath instituted at Children’s to bring people togetherafter a failure. The FEA represents a disciplined exploration of whathappened from multiple perspectives – like the proverbial blind menaround the elephant. In this setting, however, the goal is not to fightabout who was right, as the blind men did, but rather to identifycontributing factors with the goal of improving the system to prevent


similar failures in the future.6 The FEA is thus a prime example ofresponding productively.

Equally important, the blameless reporting policy enabledproductive responses to messengers who brought bad news aboutan error or mishap. Instead of expecting blame or punishment, thehealthcare personnel at Children’s began to expect – and experi-ence – appreciation for their effort in bringing valuable informationforward.

This goal of this chapter is to provide further examples of spe-cific ways leaders build psychological safety in their organizations bysetting the stage, inviting participation, and responding productively.With some practice and reflection, this tool kit is available to anyleader wishing to create psychological safety. Table 7.1 summarizesthe framework. To develop these behavioral tools, I drew from bothresearch and my years of experience studying and consulting withorganizations around the world.

How to Set the Stage for Psychological Safety

Whenever you are trying to get people on the same page, with com-mon goals and a shared appreciation for what they’re up against, you’resetting the stage for psychological safety. The most important skill tomaster is that of framing the work. If near-perfection is what is neededto satisfy demanding car customers, leaders must know to frame thework by alerting workers to catch and correct tiny deviations beforethe car proceeds down the assembly line. If zero worker fatalities in adangerous platinum mine is the goal, then leaders must frame physicalsafety as a worthy and challenging but attainable goal. If discoveringnew cures is the goal, leaders know to motivate researchers to generatesmart hypotheses for experiments and to feel okay about being wrongfar more often than right. In this section, I’ll first explaining how andwhy framing the work includes reframing failure and clarifying theneed for voice. From there I’ll move on to another stage-setting toolin the leader’s tool kit: motivating effort.

Trim Size: 6in x 9in Edmondson c07.tex V1 - 10/03/2018 7:55pm Page 159�

� �

�

159

Table 7.1 The Leader’s Tool Kit for Building Psychological Safety.

Category Setting the Stage Inviting Participation Responding Productively

Leadershiptasks

Frame the Work◾ Set expectations about

failure, uncertainty, andinterdependence to clarifythe need for voice

Emphasize Purpose◾ Identify what’s at stake,

why it matters, and forwhom

Demonstrate SituationalHumility

◾ Acknowledge gapsPractice Inquiry◾ Ask good questions◾ Model intense listeningSet up Structures and

Processes◾ Create forums for input◾ Provide guidelines for

discussion

Express Appreciation◾ Listen◾ Acknowledge and thankDestigmatize Failure◾ Look forward◾ Offer help◾ Discuss, consider, and

brainstorm next stepsSanction Clear Violations

Accomplishes Shared expectations andmeaning

Confidence that voice iswelcome

Orientation toward continuouslearning


Framing the Work

Reframing Failure

Because fear of (reporting) failure is such a key indicator of an envi-ronment with low levels of psychological safety, how leaders presentthe role of failure is essential. Recall Astro Teller’s observation atGoogle X that “the only way to get people to work on big, riskythings . . . is if you make that the path of least resistance for them[and] make it safe to fail.”7 In other words, unless a leader expresslyand actively makes it psychologically safe to do so, people will auto-matically seek to avoid failure. So how did Teller reframe failure tomake it okay? By saying, believing, and convincing others that “I’mnot pro failure, I’m pro learning.”8

Failure is a source of valuable data, but leaders must understandand communicate that learning only happens when there’s enoughpsychological safety to dig into failure’s lessons carefully. In his bookThe Game-Changer, published while he was still CEO of Proctorand Gamble, A.G. Lafley celebrates his 11 most expensive productfailures, describing why each was valuable and what the companylearned from each.9 Recall, also, Ed Catmull’s assurance to Pixaranimators, that movies always start out bad, to help them “uncouplefear and failure.”10 Here, Catmull is making a leadership framingstatement. He is making sure that people know this is the kind ofwork for which stunning success occurs only if you’re willing to con-front the “bad” along the way to the “good.” Similarly, OpenTableCEO Christa Quarles tells employees, “early, often, ugly. It’s O.K.It doesn’t have to be perfect because then I can course-correct much,much faster.”11 This too is a framing statement. It says that successin the online restaurant-reservation business occurs through coursecorrection – not through magically getting it right the first time.Quarles is framing early, ugly versions as vital information to makegood decisions that lead to later, beautiful versions.

Learning to learn from failure has become so important thatSmith College (along with other schools around the country) is


creating courses and initiatives to help students better deal withfailures, challenges, and setbacks. “What we’re trying to teach is thatfailure is not a bug of learning, it’s a feature,”12 said Rachel Simmons,a leadership development specialist in Smith’s Wurtele Center forWork and Life and the unofficial “failure czar” on campus. “It’s notsomething that should be locked out of the learning experience. Formany of our students – those who have had to be almost perfect toget accepted into a school like Smith – failure can be an unfamiliarexperience. So when it happens, it can be crippling.”13 Withworkshops on impostor syndrome, discussions on perfectionism anda campaign to remind students that 64% of their peers will get (gasp)a B-minus or lower, the program is part of a campus-wide effort tofoster student resilience.

Note that failure plays a varying role in different kinds of work.14

At one end of the spectrum is high-volume repetitive work, such asin an assembly plant, a fast-food restaurant, or even a kidney dialysiscenter. Failing to correctly plug a patient into a dialysis machine orinstall an automobile airbag in precisely the right manner can havedisastrous consequences. So in this kind of work it’s vital that peopleeagerly catch and correct deviations from best practice. Here, cele-brating failure is a matter of viewing such deviations as “good catch”events and appreciating those who noticed tiny mistakes as observantcontributors to the mission.

At the other end of the spectrum lies innovation and research,where little is known about how to obtain a desired result. Creatinga movie, a line of original clothing, or a technology that can convertseawater to fuel are all examples. In this context, dramatic failuresmust be courted and celebrated because they are and integral part ofthe journey to success. In the middle of the spectrum, where muchof the work done today falls, are complex operations, such as hospitalsor financial institutions. Here, vigilance and teamwork are both vitalto preventing avoidable failures and celebrating intelligent ones.

Reframing failure starts with understanding a basic typologyof failure types. As I have written in more detail elsewhere, failurearchetypes include preventable failures (never good news), complex


failures (still not good news), and intelligent failures (not fun, butmust be considered good news because of the value they bring).15

Preventable failures are deviations from recommended proceduresthat produce bad outcomes. If someone fails to don safety glassesin a factory and suffers an eye injury, this is a preventable failure.Complex failures occur in familiar contexts when a confluence offactors come together in a way that may never have occurred before;consider the severe flooding of the Wall Street subway station inNew York City during Superstorm Sandy in 2012. With vigilance,complex failures can sometimes, but not always, be avoided. Neitherpreventable nor complex failures are worthy of celebration.

In contrast, intelligent failures, as the term implies, must be cele-brated so as to encourage more of them. Intelligent failures, like thepreventable and complex, are still results no one wanted. But, unlikethe other two categories, they are the result of a thoughtful foray intonew territory. Table 7.2 presents definitions and contexts to clarifythese distinctions. An important part of framing is making sure peo-ple understand that failures will happen. Some failures are genuinelygood news; some are not, but no matter what type they are, ourprimary goal is to learn from them.

Clarifying the Need for Voice

Framing the work also involves calling attention to other ways,beyond failure’s prevalence, in which tasks and environments differ.Three especially important dimensions are uncertainty, interde-pendence, and what’s at stake – all of which also have implicationsfor failure (e.g. expectations about its frequency, its value, and itsconsequences). Emphasizing uncertainty reminds people that theyneed to be curious and alert to pick up early indicators of change in,say, customer preferences in a new market, a patient’s reaction to adrug, or new technologies on the horizon.

Emphasizing interdependence lets people know that they’reresponsible for understanding how their tasks interact with other

Trim Size: 6in x 9in Edmondson c07.tex V1 - 10/03/2018 7:55pm Page 163�

� �

�

163

Table 7.2 Failure Archetypes – Definitions and Implications.16

Preventable Complex Intelligent

Definition Deviations from knownprocesses that produceunwanted outcomes

Unique and novelcombinations of eventsand actions that give riseto unwanted outcomes

Novel forays into newterritory that lead tounwanted outcomes

Common Causes Behavior, skill, and attentiondeficiencies

Complexity, variability, andnovel factors imposed onfamiliar situations

Uncertainty,experimentation, andrisk taking

Descriptive Term Process deviation System breakdown Unsuccessful trial

Contexts Where EachIs Most Salient

Production line manufacturingFast-food servicesBasic utilities and services

Hospital careNASA shuttle programAircraft carrierNuclear power plant

Drug developmentNew product design


people’s tasks. Interdependence encourages frequent conversations tofigure out the impact their work is having on others and to conveyin turn the impact others’ work has on them. Interdependent workrequires communication. In other words, when leaders frame thework they are emphasizing the need for taking interpersonal riskslike sharing ideas and concerns.

Finally, clarifying the stakes is important whether the stakes arehigh or low. Reminding people that human life is on the line – say,in a hospital, a mine, or at NASA – helps put interpersonal risk inperspective. People are more likely to speak up – thereby overcomingthe inherent asymmetry of voice and silence – if leaders frame itsimportance. Similarly, reminding people that the only thing that is atstake is a bruised ego when a lab experiment doesn’t go as hoped is agood way to get them to be willing to go for it – offer possibly crazyideas and figure out which ones to test first!

Finally, how most people see bosses presents a crucial area forreframing. Table 7.3 compares a set of default frames to a deliberatereframe for how we might think about bosses and others at work.As a default, bosses are viewed as having answers, being able to giveorders, and being positioned to assess whether the orders are wellexecuted. With this frame, others are merely subordinates expectedto do as they are told. CEO Martin Winterkorn at VW is a primeexample of an executive governed by the default frame. Noticethat the default set of frames makes interpersonal fear sensible.

Table 7.3 Framing the Role of the Boss.

Default Frames Reframe

The Boss Has answersGives orders

Assesses others’performance

Sets directionInvites input to clarify and

improveCreates conditions for continued

learning to achieve excellence

Others Subordinates who mustdo what they’re told

Contributors with crucialknowledge and insight


In a world in which bosses have the answers and absolute authorityover how your work is judged, it makes sense to fear the boss and tothink very carefully about what you reveal. The reframe, in contrast,spells out logic that clarifies the necessity for a psychologically safeenvironment. This logic applies to the successful execution of workin most organizations today.

The reframe shows that leaders must establish and cultivate psy-chological safety to succeed in most work environments today.The leader is obliged to set direction for the work, to invite rele-vant input to clarify and improve on the general direction that hasbeen set, and to create conditions for continued learning to achieveexcellence. Cynthia Carroll reframed the work at Anglo Americanby actively inviting the miners’ input to draw up new physical safetypractices. Naohiro Masuda, the plant superintendent for FukushimaDaini, reframed the work when he set up a whiteboard to lead histeam successfully through a tsunami’s onslaught. He gave the team asmuch ongoing information as he had available in a quickly chang-ing environment. The more creativity and innovation are required toachieve a particular goal, the more this stance is needed. The problemwith Winterkorn’s stance at VW wasn’t that it was wrong in a moralsense; rather, it was wrong in a practical sense; it was wrong for achiev-ing a goal that called for innovation. Making the company the largestautomaker in the world by leveraging diesel engine technology wassomewhat of a “moonshot” goal such as those pursued at Google X.The diesel engine technology was not yet able to perform in waysconsistent with regulatory requirements; no amount of giving orderscould overcome that basic truth about the situation. A psychologicallysafe environment, such as we saw at Google X, could have produc-tively absorbed this innovation failure, allowing the senior executivesto rethink their strategy.

In the reframe, those who are not the boss are seen as valuedcontributors – that is, as people with crucial knowledge and insight.When Julie Morath asks people to speak up about patient error orwhen Eileen Fisher orchestrates staff meetings to give everyone achance to speak, they do so because it will improve decision-makingand execution – not because they want to be nice. Leaders in a


volatile, uncertain, complex, and ambiguous (VUCA) world, whounderstand that today’s work requires continuous learning to figureout when and how to change course, must consciously reframehow they think, from the default frames that we all bring to workunconsciously to a more productive reframe.

Framing the work is not something that leaders do once, and thenit’s done. Framing is ongoing. Frequently calling attention to levelsof uncertainty or interdependence helps people remember that theymust be alert and candid to perform well. Had NASA leaders empha-sized these essential features of the work, the invitation to engineersto share tentative concerns would have been far more visible to them.

Motivating Effort

Emphasizing a sense of purpose is another key element of setting thestage for psychological safety. Motivating people by articulating acompelling purpose is a well-established leadership task. Leaders whoremind people of why what they do matters – for customers, for theworld – help create the energy that carries them through challengingmoments. Kent Thiry’s “one for all and all for one” motto motivatesstaff at DaVita to care for patients with kidney disease. In this motto,he at once reminds people of patients’ vulnerability and remindsthem that the team is all in it together. Note that even when it seemsobvious (for instance, taking care of vulnerable patients) that thework is meaningful, leaders still must take the time to emphasize thepurpose the organization serves. This is because anyone can get tired,distracted, and frustrated and lose sight of the larger picture – ofwhat’s at stake. Carroll brought her passion for zero harm to theSouth African government and larger mining institutional bodies.Once stakeholders from previously disconnected groups beganworking together for the shared goal of safety in the mines they wereable to develop trust for one another. It’s the leader’s job to bringpeople back to a psychological place where they are in touch withhow much their work matters. This also helps the overcome theinterpersonal risks they face at work.


Meaning can be defined and framed in other ways, too. Ray Dalioat Bridgewater Associates emphasizes to his hedge fund employeesthat personal growth is as important as profit. That each employeeis becoming a better person matters to Dalio, and he hopes to themas well. Bob Chapman’s belief that the company measures success byhow well it touches the lives of employees motivates all to bring theirbest selves to the job.

Most leaders would be well served by stopping to reflect onthe purpose that motivates them and makes the organization’s workmeaningful to the broader community. Having done so, they shouldask themselves how often and how vigorously they are conveyingthis compelling rationale for the work to others. Our primal need tofeel purpose and meaning in our lives, including at work, has beendemonstrated by numerous studies in psychology.17

How to Invite Participation So People Respond

The second essential activity in the leaders’ tool kit is inviting par-ticipation in a way that people find compelling and genuine. Thegoal is to lower what is usually a too-high bar for what’s consideredappropriate participation. Realizing that self-protection is natural, theinvitation to participate must be crystal clear if people are going tochoose to engage rather than to play it safe. Two essential behaviorsthat signal an invitation is genuine are adopting a mindset of situa-tional humility and engaging in proactive inquiry. Designing struc-tures for input, another powerful tool I discuss in this section, alsoserves as an invitation for voice.

Situational Humility

The bottom line is that no one wants to take the interpersonal riskof imposing ideas when the boss appears to think he or she knowseverything. A learning mindset, which blends humility and curiosity,


mitigates this risk. A learning mindset recognizes that there is alwaysmore to learn.

Frankly, adopting a humble mindset when faced with thecomplex, dynamic, uncertain world in which we all work today issimply realism. The term situational humility captures this conceptwell (the need for humility lies in the situation) and may make iteasier for leaders, especially those with abundant self-confidence, torecognize the validity, and the power, of a humble mindset. MITProfessor Ed Schein calls this “Here-and-Now Humility.”18 Keep inmind that confidence and humility are not opposites. Confidencein one’s abilities and knowledge, when warranted, is far preferableto false modesty. But humility is not modesty, false or otherwise.Humility is the simple recognition that you don’t have all theanswers, and you certainly don’t have a crystal ball. Research showsthat when leaders express humility, teams engage in more learningbehavior.19

Demonstrating situational humility includes acknowledging yourerrors and shortcomings. Anne Mulcahy, Chairperson and CEO ofXerox, who led the company through a successful transformationout of bankruptcy in the 2000s, said that she was known to manyin the company as the “Master of I Don’t Know” because ratherthan offer an uninformed opinion she would so often reply, “I don’tknow,” to questions.20 Although reminiscent of Eileen Fisher’s “Be aDon’t Knower,” Mulcahy adopts this stance as the newly promotedchief executive of a global corporation rather than as a founder of herown company. Speaking to executives in the Advanced ManagementProgram at Harvard Business School, Mulcahy commented thather willingness to be vulnerable with others and admit her ownshortcomings turned out to be a huge asset. “Instead of people losingconfidence, they actually gain confidence [in you] when you admityou don’t know something,” she said.21 This created the space forothers at Xerox to step up, offer their expertise, and engage in theprocess of turning the company around. Although this may seemdownright obvious, such humility can be strangely rare in manyorganizations.


London Business School Professor Dan Cable sheds light on why.In a recent article in Harvard Business Review, he writes, “Power . . .can cause leaders to become overly obsessed with outcomes andcontrol,” inadvertently ramping up “people’s fear – fear of nothitting targets, fear of losing bonuses, fear of failing – and as aconsequence . . . their drive to experiment and learn is stifled.”22

Being overly certain or just plain arrogant can have similar effects –increasing fear, reducing motivation, and inhibiting interpersonalrisk taking.

Recall that in our study of neonatal intensive care units men-tioned in Chapter 2, Ingrid Nembhard, Anita Tucker, and I foundthat NICUs with high psychological safety had substantially betterresults from their quality improvement work than those with low psy-chological safety.23 A factor we called leadership inclusiveness madethe difference. To illustrate, inclusive Medical Directors (physiciansin charge of the intensive care organization) said things like, “I maymiss something; I need to hear from you.” Others perhaps took itfor granted that people knew to speak up. Our survey measure ratedthree behavioral attributes of leadership inclusiveness: one, leaderswere approachable and accessible; two, leaders acknowledged theirfallibility; and three, leaders proactively invited input from otherstaff, physicians, and nurses. The concept of leadership inclusivenessthus captures situational humility coupled with proactive inquiry(discussed in the next section).

Building on this work, Israeli researchers Reuven Hirak andAbraham Carmeli and two of their colleagues surveyed employeesfrom clinical units in a large hospital in Israel on leader inclusiveness,psychological safety, units’ ability to learn from failures, and unitperformance. They found that units in which leaders were perceivedas more inclusive had higher psychological safety, which led toincreased learning from failure and better unit performance.24 Insum, leaders who are approachable and accessible, acknowledge theirfallibility, and proactively invite input from others can do much toestablish and enhance psychological safety in their organizations.Powerful tools, indeed.


Proactive Inquiry

The second tool for inviting participation is inquiry. Inquiry ispurposeful probing to learn more about an issue, situation, or person.The foundational skill lies in cultivating genuine interest in others’responses. Why is this hard? Because all adults, especially high-achieving ones, are subject to a cognitive bias called naive realism thatgives us the experience of “knowing” what’s going on.25 As noted inthe previous section, we believe we are seeing “reality” – rather thana subjective view of reality. As a result, we often fail to wonder whatothers are seeing. We fail to be curious. Worse, many leaders, evenwhen they are motivated to ask a question, worry that it will makethem look uninformed or weak. Further exacerbating the challenge,some companies sport “a culture of telling,” as a senior executive ina global pharmaceutical company put it in a recent conversation wehad about his company. In a culture of telling, asking gets short shrift.

Yet when leaders overcome these biases to ask genuine questions,it fosters psychological safety. Recall Morath at Children’s Hospital:Was everything as safe as you would like it to have been this weekwith your patients? Or Carroll’s question to the mineworkers: Whatdo we need to create a work environment of care and respect? Gen-uine questions convey respect for the other person – a vital aspectof psychological safety. Contrary to what many may believe, askingquestions tends to make the leader seem not weak but thoughtfuland wise.

The leaders’ tool kit contains a few rules of thumb for asking agood question: one, you don’t know the answer; two, you ask ques-tions that do not limit response options to Yes or No, and three, youphrase the question in a way that helps others share their thinkingin a focused way. Consistent with these basic principles, the WorldCafé organization, which is dedicated to fostering conversations thatfocus on finding new ways to accomplish important organizational orsocial goals, identifies attributes of “powerful questions” – those thatprovoke, inspire, and shift people’s thinking – as shown in the sidebar.


Attributes of a Powerful Question26

◾ Generates curiosity in the listener◾ Stimulates reflective conversation◾ Is thought-provoking◾ Surfaces underlying assumptions◾ Invites creativity and new possibilities◾ Generates energy and forward movement◾ Channels attention and focuses inquiry◾ Stays with participants◾ Touches a deep meaning◾ Evokes more questions

All of us can benefit from introducing more inquiry into ourwork. The essential skill of inquiry involves picking the right typeof question for a situation. For instance, questions can go broador deep. To broaden understanding of a situation or expand anoption set, ask, “what might we be missing?”, “what other ideascould we generate?”, or “who has a different perspective?”27 Suchquestions ensure that more comprehensive information is consideredand that a larger set of options is generated related to a problemor decision. Other questions are designed to deepen understand-ing. Ask, “what leads you to think so?” or “can you give me anexample?” Such questions are crucial to helping people learn abouteach other’s expertise and goals. Moreover, when asked thoughtfully,a good question indicates to others that their voices are desired –instantly making that moment psychologically safe for offeringa response.

Bob Pittman, founder of MTV, offers an example of inquiry topush for depth of analysis and diversity of perspective at the sametime. In an interview with former New York Times “Corner Office”writer Adam Bryant, Pittman recounts,


Often in meetings, I will ask people when we’re discussing an idea, “Whatdid the dissenter say?” The first time you do that, somebody might say,“Well, everybody’s on board.” Then I’ll say, “Well, you guys aren’t listen-ing very well, because there’s always another point of view somewhere andyou need to go back and find out what the dissenting point of view is.”28

Here we can see that Pittman is practicing proactive inquiry andalso modeling to his employees how to do it. Further, the idea thatthere’s always another point of view is a subtle move to frame thework. In this small point, he is framing the work, implicitly remind-ing the team that creative programming work, such as practiced atMTV, benefits from a diversity of views. For more cases and detail onthe power of inquiry as a fundamental leadership skill, I recommendEd Schein’s thoughtful book, Humble Inquiry.29

Designing Structures for Input

A third way to invite participation and reinforce psychological safetyis to implement structures designed to elicit employee input. Thefocus groups and FEA meetings at Children’s are examples of suchstructures. These were so successful in getting conversations on safetyunderway that hospital staff members began to design structures oftheir own to elicit their own colleagues’ ideas and concerns. Notably,Casey Hooke, a clinical nurse specialist, came up with the idea for asafety action team in her unit. The cross-functional unit-based teammet monthly to identify safety hazards in the oncology unit. Soon,two other units, inspired by Hooke’s efforts, launched their own safetyaction teams. Eventually, the patient safety steering committee sug-gested that all hospital units implement such teams.

Another way to chip away at interpersonal fear is throughemployee-to-employee learning structures, as Google has done withits creation of the “g2g” (Googler-to-Googler) network, consistingof more than 6000 Google employees who volunteer time to helpingtheir peers learn.30 Participants in g2g do one-on-one mentoring,coach teams on psychological safety, and teach courses in professional


skills ranging from leadership to Python coding. Google claims thatg2g has helped develop the skills of countless employees. It is alsohelping to build a psychologically safe culture where everyone isboth a learner and a teacher.

The global food company Groupe Danone created structuredconference events called “knowledge marketplaces” to foster inquiryand knowledge sharing across country business units.31 Althoughmany good ideas and practices that improved operational perfor-mance came out of these workshops, which brought employees fromdifferent countries together, the executives who sponsored them sawthe most important outcome as a shift in the organizational culturetoward speaking up, asking for help, and sharing good ideas.

How to Respond Productively to Voice – NoMatter Its Quality

To reinforce a climate of psychological safety, it’s imperative thatleaders – at all levels – respond productively to the risks peopletake. Productive responses are characterized by three elements:expressions of appreciation, destigmatizing failure, and sanctioningclear violations.

Express Appreciation

Imagine if Christina, the NICU nurse in Chapter 1, had spoken upto Dr. Drake. Her quiet fear was that he would have berated or belit-tled her. But what if he had said, “thank you so much for bringingthat up”? Her feeling of psychological safety would have gone up anotch. This is an example of an appreciative response. It does notmatter whether the doctor believes the nurse’s suggestion or questionis good or bad. Either way, his initial response must be one of appreci-ation. Then he can educate – that is, give feedback or explain clinicalsubtleties. But to ensure that staff keeps speaking up so as to keep


patients safe from unexpected lapses in attention or judgment, thecourage it takes to speak up must receive the mini-reward of thanks.

Stanford Professor Carol Dweck, whose celebrated research onmindset shows the power of a learning orientation for individualachievement and resilience in the face of challenge, notes the impor-tance of praising people for efforts, regardless of the outcome.32 Whenpeople believe their performance is an indication of their ability orintelligence, they are less likely to take risks – for fear of a result thatwould disconfirm their ability. But when people believe that perfor-mance reflects effort and good strategy, they are eager to try newthings and willing to persevere despite adversity and failure.

Praising effort is especially important in uncertain environments,where good outcomes are not always the result of good process,and vice versa. Although many of the examples in this book presentresponses from CEOs, an equally important leadership responsibilityfor C-level executives is making sure that people throughout theorganization respond productively to their colleagues. It helps ifeveryone understands the logic conveyed in Figure 7.1, whichdepicts the imperfect relationship between process and outcome.Clearly, good process can lead to good outcomes, and bad processcan lead to bad outcomes (Figure 7.1a). But, as shown in Figure 7.1b,good process also can produce bad outcomes (especially facing highuncertainty or complexity, as in VUCA conditions), and bad processcan produce a good outcome (when you get lucky), or the illusionof a good outcome (for a while, anyway, as in the cases of VWand Wells Fargo). The lack of simple cause-effect relationships inuncertain, ambiguous environments reinforces the importance ofproductive responses to outcomes of all kinds, but especially to badnews outcomes.

Productive responses often include expressions of appreciation,ranging from the small (“thank you so much for speaking up”) tothe elaborate – celebrations or bonuses in response to intelligentfailure.


Good Process

Bad Process

Good Outcomeoften leads to...

often leads to...

(a)

(b)

Bad Outcome

Good Process

Bad Process

Good Outcome

VUCA

Luck

Bad Outcome

Figure 7.1 The Imperfect Relationship between Process andOutcome.

Destigmatize Failure

Failure is a necessary part of uncertainty and innovation, but this mustbe made explicit to reinforce the invitation for voice. Consider theimplications of the failure typology in Table 7.2 for designing a pro-ductive response to news of a failure. Leaders who respond to allfailures in the same way will not create a healthy environment forlearning. When a failure occurs because someone violated a rule orvalue that matters in the organization, this is very different than whena thoughtful hypothesis in the lab turns out to be wrong. Althoughobvious in concept, in practice people routinely get this wrong.


Table 7.4 Destigmatizing Failure for Psychological Safety.

TraditionalFrame

DestigmatizingReframe

Concept ofFailure

Failure is notacceptable.

Failure is a natural by-product ofexperimentation.

Beliefs AboutEffectivePerformance

Effectiveperformersdon’t fail.

Effective performers produce,learn from and share the lessonsfrom intelligent failures.

The Goal Prevent failure. Promote fast learning.The Frame’s

ImpactPeople hide

failures toprotectthemselves.

Open discussion, fast learning,and innovation.

I frequently ask managers, scientists, salespeople, and technologistsaround the world the following question: What percent of the fail-ures in your organizations should be considered blameworthy? Theiranswers are usually in single digits – perhaps 1% to 4%. I then askwhat percent are treated as blameworthy. Now, they say (after a pauseor a laugh) 70% to 90%! The unfortunate consequence of this gapbetween simple logic and organizational response is that many fail-ures go unreported and their lessons are lost. As shown in Table 7.4,the primary result of responding to failures in a negative way is thatyou don’t hear about them. And that, as Mark Costa noted in Chapter2, should be your biggest fear.

A productive response to a complex failure at Children’s Hospitalis embodied in the FEA process, described in the Leader’s Tool Kitsection. All of the people whose work or role touched the failure inquestion are invited to sit around the same table to share their obser-vations, their questions, and their concerns related to the events thatunfolded. Everyone listens intently to what others saw, felt, and did.More often than not, individuals were doing their tasks in prescribed


ways, but a host of factors came together in a new way to producea mishap. The FEA is not a fun activity, but it is deeply meaningfuland gratifying. People gain understanding of how various systems androles in the hospital intersect, and they leave with a deeper appreci-ation of system complexity and interdependence. They do not feelblamed but instead empowered to go back out and make the systembetter so as to prevent a similar failure in the future. Most impor-tantly, they feel psychologically safe enough to keep reporting whatthey see, to keep asking for help or clarification, and to offer ideasfor improvement.

In fact, a productive response to intelligent failure can meanactually celebrating the news. Some years ago, the chief scientificofficer at Eli Lilly introduced “failure parties” to honor intelligent,high-quality scientific experiments that failed to achieve the desiredresults.33 Might this be a bridge too far? I don’t think so. First,and most obvious, it helps build a psychologically safe climate forthoughtful risks, which is mission critical in science. Second, it helpspeople acknowledge failures in a timely way, which allows redeploy-ment of valuable resources – scientists and materials – to new projectsearlier rather than later, potentially saving thousands of dollars.Third, when you hold a party, people tend to show up – whichmeans they learn about the failure. This in turn lowers the risk thatthe company will repeat the same failure. An intelligent failure thefirst time around no longer qualifies as intelligent the second time.

In brief, a productive response to preventable failures is to doubledown on prevention, usually a combination of training and improvedsystem design to make it easier for people to do the right thing. How-ever, there are instances in which a preventable failure is the result ofa blameworthy action or a repeated instance of deviation from pre-scribed process, impervious to prior attempts at redirection. In suchcases, usually rare, there is an obligation to act in ways that preventfuture occurrence. This may mean fines or other sanctions, and insome cases even firing someone.


Sanction Clear Violations

Yes, firing can sometimes be an appropriate and productive response –to a blameworthy act. But won’t this kill the psychological safety?No. Most people are thoughtful enough to recognize (and appreci-ate) that when people violate rules or repeatedly take risky shortcuts,they are putting themselves, their colleagues, and their organization atrisk. In short, psychological safety is reinforced rather than harmed byfair, thoughtful responses to potentially dangerous, harmful, or sloppybehavior.

In July 2017, Google engineer James Damore wrote a 10-pagememo railing against the company’s diversity stance, arguing that bio-logical differences explained why Google had fewer women engineersand paid them less well than men, and circulated it widely withinthe company.34 Someone then leaked the memo, creating a publicfirestorm.35

How did Google respond? Damore was promptly and publiclyfired a month later, earning the company both praise and criticism.Thoughtful arguments have been made on both sides of the firingdebate. Rather than coming out on one side or the other, let’s stepback to consider when firing constitutes a “productive response,” andwhen it doesn’t.

Take this specific case. To begin, it is a shame that Damore choseto share his personal concerns electronically and widely within thecompany, all but ensuring that someone who disliked the memowould share it publicly. Ideally, an employee with an opinion toexpress related to an important work issue or policy would first solicitfeedback from colleagues, especially with those who might be likelyto have a different view. The person might want to first learn moreabout the potential impact of those ideas and the forms in which theycould be expressed. Very few of us are able to see complex issues frommultiple perspectives and consider the potential consequences wellenough to make good decisions about them alone. This doesn’t matterwhen stakes are low. But stakes are high when a document that affectsyour colleagues, customers, or company may be read by millions.


But, once the inflammatory memo has been made public, howshould a company respond? My intention is not to illuminate thespecifics of Damore’s memo at Google but rather to suggest a generalstrategy for productive responses to actions or events in your organi-zation that you wish had not occurred.

If there are clear policies against the use of company emailaddresses or social media platforms for the expression of personalopinions, then an employee who violates these policies commits whatwe can call a blameworthy act. In this case, a productive responseindeed involves tough sanctions, which may include terminatingthe employee. A tough response is productive because it lets peopleknow that the company is serious about its policies and values, whichshapes future behavior, and because it constitutes a fair response to astated violation.

If policies are unclear, however, a productive response is onethat turns the unfortunate event into a different kind of learningopportunity – for the company and sometimes for the interestedpublic. In the Damore case, executives might express dismay at theemployee’s opinion (and perhaps dismay at his ignorance of a largerset of societal forces that have systematically diminished advancementopportunities for certain demographic groups over decades). Theymight then go on to explain their plans for educating employees onwhat they believe to be the value of a diverse workforce. As part ofthis organizational learning process, company managers at all levelswould elicit and listen to ideas, questions, concerns, and frustra-tions. They might create opportunities for engaging in perspectivetaking, building empathy, developing inquiry skills, and more. Theorganization might also seek ways to come up with new, improvedways to leverage employee diversity to build better products andservices.

In short, a productive response is concerned with future impact.Punishment sends a powerful message, and an appropriate one ifboundaries were clear in advance. Indeed, it is vital to send messagesthat reinforce values the company holds dear. However, it is equallyvital not to inadvertently send a message that says, “diverse opinions


simply won’t be tolerated here,” or “one strike and you’re out.”Such messages reduce psychological safety and ultimately erodethe quality of the work. In contrast, a message that reinforces thevalues and practices of a learning organization is, “it’s okay to makea mistake, and it’s okay to hold an opinion that others don’t like,so long as you are willing to learn from the consequences.” Themost important goal is figuring out a way to help the organizationlearn from what happened. And so, if there is ambiguity aboutpublic self-expression related to company policies, then a productiveresponse is one that engages people in a learning dialogue to betterunderstand and improve how the company functions. Table 7.5shows how a productive response to failure in an organization shouldvary for different failure types.

Table 7.5 Productive Responses to Different Typesof Failure.

PreventableFailure

ComplexFailure

IntelligentFailure

ProductiveResponse

– Training

– Retraining

– Processimprovement

– System redesign

– Sanctions, ifrepeated orotherwiseblameworthyactions arefound

– Failure analysisfrom diverseperspectives

– Identificationof risk factorsto address

– Systemimprovement

– Failure parties

– Failure awards

– Thoughtfulanalysis ofresults to figureout implications

– Brainstormingof newhypotheses

– Design of nextsteps oradditionalexperiments


Leadership Self-Assessment

The practices described in this chapter are dominated by complexinterpersonal skills and thus not easy to master. They take time, effort,and practice.36 Perhaps the most important aspect of learning them isto practice self-reflection. A set of self-assessment questions, providedin a sidebar, can be used to do just that. The questions map to andoperationalize the framework introduced in this chapter.

Leadership Self-Assessment

I. Setting the StageFraming the work

◾ Have I clarified the nature of the work? To what extent is thework complex and interdependent? How much uncertaintydo we face? How often do I refer to these aspects of thework? How well do I assess shared understanding of thesefeatures?

◾ Have I spoken of failures in the right way, given the nature ofthe work? Do I point out that small failures are the currencyof subsequent improvement? Do I emphasize that it is notpossible to get something brand new “right the first time?”

Emphasizing Purpose

◾ Have I articulated clearly why our work matters, why itmakes a difference, and for whom?

◾ Even if it seems obvious given the type of work or industryI’m in, how often do I talk about what’s at stake?

II. Inviting ParticipationSituational Humility

◾ Have I made sure that people know that I don’t think I haveall the answers?

◾ Have I emphasized that we can always learn more? Have Ibeen clear that the situation we’re in requires everyone to behumble and curious about what’s going to happen next?


Proactive Inquiry

◾ How often do I ask good questions rather than rhetoricalones? How often do I ask questions of others, rather thanjust expressing my perspective?

◾ Do I demonstrate an appropriate mix of questions that gobroad and go deep?

Systems and Structures

◾ Have I created structures to systematically elicit ideas andconcerns?

◾ Are these structures well designed to ensure a safe environ-ment for open dialogue?

III. Responding ProductivelyExpress Appreciation

◾ Have I listened thoughtfully, signaling that what I am hear-ing matters?

◾ Do I acknowledge or thank the speaker for bringing the ideaor question to me? Listen thoughtfully

Destigmatize Failure

◾ Have I done what I can to destigmatize failure? What morecan I do to celebrate intelligent failures?

◾ When someone comes to me with bad news, how do I makesure it’s a positive experience?

◾ Do I offer help or support to guide the next steps?

Sanction Clear Violations

◾ Have I clarified the boundaries? Do people know what con-stitute blameworthy acts in our organization?

◾ Do I respond to clear violations in an appropriately toughmanner so as to influence future behavior?


Chapter 7 Takeaways

◾ Three interrelated practices help create psychological safety –setting the stage, inviting participation, and respondingproductively.

◾ These practices must be repeatedly used, in interactive,learning-oriented ways, to create and restore a climate ofcandor in an ongoing way.

◾ Building and reinforcing psychological safety is the responsi-bility of leaders at all levels of the organization.

Endnotes

1. This quote is from Gelb, M.J. Thinking for a Change: Discovering the Powerto Create, Communicate, and Lead. Harmony, 1996. Print, pp. 96.

2. The details on Julie Morath at Children’s Hospital draw from a casestudy that I conducted with my colleagues Mike Roberto and AnitaTucker: Edmondson, A.C., Roberto, M., & Tucker, A.L. Children’sHospital and Clinics (A). Case Study. HBS Case No. 302-050. Boston:Harvard Business School Publishing, 2001.

3. For additional details on framing, see Chapter 3 of Edmondson, A.C.Teaming: How Organizations Learn, Innovate, and Compete in the KnowledgeEconomy. San Francisco: Jossey-Bass, 2011. Print, pp. 83–113.

4. Edmondson, A.C., Nembhard, I.M., & Roloff, K.S. Children’s Hospitaland Clinics (B). Case Study. HBS Case No. 608-073. Boston: HarvardBusiness School Publishing, 2007.

5. Edmondson, A.C. et al. Children’s Hospital and Clinics (A). 2001, opcit.

6. One version of the famous fable is found in an 1872 poem by JohnGodfrey Saxe, which includes these lines: “And so these men ofIndostan disputed loud and long, each in his own opinion exceedingstiff and strong. Though each was partly in the right, and all were in


the wrong.” The full poem can be found here: https://en.wikisource.org/wiki/The_poems_of_John_Godfrey_Saxe/The_Blind_Men_and_the_Elephant Accessed June 12, 2018.

7. Teller, A. “The Unexpected Benefit of Celebrating Failure.” TED.2016. https://www.ted.com/talks/astro_teller_the_unexpected_benefit_of_celebrating_failure Accessed June 8, 2018.

8. This quote comes from a talk Teller gave at Stanford University onApril 20, 2016 as part of Stanford’s Entrepreneurial Thought Leadersseries. You can watch the full talk at Stanford’s eCorner: https://ecorner.stanford.edu/video/celebrating-failure-fuels-moonshots-entire-talk/.

9. Lafley, A.G., & Charan, R. The Game-Changer: How You Can DriveRevenue and Profit Growth with Innovation. 1st ed. Crown Business, 2008.Print.

10. Catmull, E. & Wallace, A. Creativity, Inc.: Overcoming the Unseen ForcesThat Stand in the Way of True Inspiration. New York: Random House,2013. Print, pp. 123.

11. Bryant, A. “Christa Quarles of OpenTable: The Advantage of ‘Early,Often, Ugly.” The New York Times. April 12, 2016. https://www.nytimes.com/2016/08/14/business/christa-quarles-of-opentable-the-advantage-of-early-often-ugly.html Accessed June 14, 2018.

12. Bennett, J. “On Campus, Failure Is on the Syllabus.” The NewYork Times. June 24, 2017. https://www.nytimes.com/2017/06/24/fashion/fear-of-failure.html Accessed June 14, 2018.

13. Ibid.14. For more on different types of work, see Chapter 1 of Teaming: How

Organizations Learn, Innovate, and Compete in the Knowledge Economy. SanFrancisco: Jossey-Bass, 2012. Print, pp. 11–43.

15. Edmondson, A.C. “Strategies for Learning from Failure.” HarvardBusiness Review. April 2011. https://hbr.org/2011/04/strategies-for-learning-from-failure Accessed June 14, 2018.

16. This table presents a modified version of a table that appeared in Chapter5 of Edmondson, A.C. Teaming: How Organizations Learn, Innovate, andCompete in the Knowledge Economy. San Francisco: Jossey-Bass, 2012.Print, pp. 166.

17. To cite just one example, Wharton professor Adam Grant and a teamof researchers conducted a study in which they arranged for a groupof university call center workers, tasked with the tedious and frustrat-ing work of trying to raise money for the university’s scholarship fund,to meet the actual scholarship recipients funded by the donations theysolicited. By seeing how their work contributed to the lives of others,

https://en.wikisource.org/wiki/The_poems_of_John_Godfrey_Saxe/The_Blind_Men_and_the_Elephant




https://ecorner.stanford.edu/video/celebrating-failure-fuels-moonshots-entire-talk

https://ecorner.stanford.edu/video/celebrating-failure-fuels-moonshots-entire-talk

https://www.nytimes.com/2016/08/14/business/christa-quarles-of-opentable-the-advantage-of-early-often-ugly.html



https://www.nytimes.com/2017/06/24/fashion/fear-of-failure.html

https://www.nytimes.com/2017/06/24/fashion/fear-of-failure.html

https://hbr.org/2011/04/strategies-for-learning-from-failure

https://hbr.org/2011/04/strategies-for-learning-from-failure

https://www.ted.com/talks/astro_teller_the_unexpected_benefit_



the callers subsequently increased both the time they spent on the phoneand how much money they brought in, compared to callers who didnot meet the scholarship recipients. See Grant, A.M., Campbell, E.M.,Chen, G., Cottone, K., Lapedis, D., & Lee, K. “Impact and the Artof Motivation Maintenance: The Effects of Contact with Beneficiarieson Persistence Behavior.” Organizational Behavior and Human DecisionProcesses 103.1 (2007): 53–67.

18. Schein, E.H. Humble Inquiry: the Gentle Art of Asking Instead of Telling.1st ed. Berrett-Koehler Publishers, Inc., 2013. Print, pp. 11.

19. Owens, B.P., Johnson, M.D., & Mitchell, T.R. “Expressed Humility inOrganizations: Implications for Performance, Teams, and Leadership.”Organization Science 24.5 (2013): 1517–38.

20. Anne Mulcahy, HBS class comments, October 11, 2017.21. Ibid.22. Cable, D. “How Humble Leadership Really Works.” Harvard Business

Review. April 23, 2018. https://hbr.org/2018/04/how-humble-leadership-really-works Accessed June 14, 2018.

23. Tucker, A.L., Nembhard, I.M., and Edmondson, A.C. “Implementingnew practices: An empirical study of organizational learning in hospitalintensive care units.” Management Science 53.6 (2007): 894 –907.

24. Hirak, R., Peng, A.C., Carmeli, A., & Schaubroeck, J.M. “LinkingLeader Inclusiveness to Work Unit Performance: The Importance ofPsychological Safety and Learning from Failures.” The Leadership Quar-terly 23.1 (2012): 107–17.

25. Ross, L. & Ward, A. “Naive Realism: Implications for Social Con-flict and Misunderstanding.” In Values & Knowledge. Ed. T. Brown, E.S.Reed, & E. Turiel. Lawrence Erlbaum Associates (1996): 103–35.

26. Adapted from “The Art of Powerful Questions.” World Café. http://www.theworldcafe.com Accessed July 27, 2018.

27. For great work on advocacy and inquiry, the Actionsmith group poststhis paper: http://actionsmithnetwork.net/wp-content/uploads/2015/09/Advocacy-and-Inquiry-Article_Final.pdf . Accessed June 21, 2018.

28. Bryant, A. “Bob Pittman of Clear Channel, on the Value of Dissent”The New York Times. November 16, 2013. https://www.nytimes.com/2013/11/17/business/bob-pittman-of-clear-channel-on-the-value-of-dissent.html Accessed June 14, 2018.

29. Schein, E.H. Humble Inquiry: The Gentle Art of Asking Instead of Telling.1st ed., Berrett-Koehler Publishers, Inc., 2013. Print.

30. “Guide: Create an Employee-to-Employee Learning Pro-gram.” re:Work. https://rework.withgoogle.com/guides/learning-

https://hbr.org/2018/04/how-humble-leadership-really-works

https://hbr.org/2018/04/how-humble-leadership-really-works

http://www.theworldcafe.com

http://www.theworldcafe.com

http://actionsmithnetwork.net/wp-content/uploads/2015/09/Advocacy-and-Inquiry-Article_Final.pdf

http://actionsmithnetwork.net/wp-content/uploads/2015/09/Advocacy-and-Inquiry-Article_Final.pdf

https://www.nytimes.com/2013/11/17/business/bob-pittman-of-clear-channel-on-the-value-of-dissent.html



https://rework.withgoogle.com/guides/learning-development-employee-to-employee/steps/introduction


development-employee-to-employee/steps/introduction/ AccessedJune 14, 2018.

31. For more on Danone’s knowledge marketplaces, see the following casestudy I conducted with David Lane: Edmondson, A.C. & Lane, D.Global Knowledge Management at Danone (A) (Abridged). Case Study.HBS No. 613-003. Boston, MA: Harvard Business School Publishing,2012.

32. For more on Dweck’s fantastic work on fixed vs. growth mindsets, seeDweck, C.S. Mindset: The New Psychology of Success. Updated ed. Ran-dom House, 2016. Print.

33. Burton, T. “By Learning From Failures, Lilly Keeps Drug PipelineFull.” The Wall Street Journal. April 21, 2004. https://www.wsj.com/articles/SB108249266648388235 Accessed June 14, 2018.

34. The memo was first leaked to the public here: https://gizmodo.com/exclusive-heres-the-full-10-page-anti-diversity-screed-1797564320Accessed June 15, 2018.

35. See, for example:◾ Wakabayashi, D. “Contentious Memo Strikes Nerve Inside Google

and Out.” The New York Times. August 8, 2017. https://www.nytimes.com/2017/08/08/technology/google-engineer-fired-gender-memo.html Accessed June 14, 2018.

◾ Molteni, M. & Rogers, A. “The Actual Science of James Damore’sGoogle Memo.” WIRED. August 15, 2017. https://www.wired.com/story/the-pernicious-science-of-james-damores-google-memo/ Accessed June 14, 2018.

36. The late HBS Professor David A. Garvin, a friend and colleague, wasfond of telling students that any word in the English language thatends in the suffix “ing” is a process, which means first, that it’s not aone-and-done, and second, that a leader can get better at it with prac-tice. In that vein, creating psychological safety in an organization isa messy process that requires leaders to set the stage, invite participa-tion, and respond productively each and every day. It never ends! Butjust like you can optimize a manufacturing process, you can definitelyimprove at it.

https://rework.withgoogle.com/guides/learning-development-employee-to-employee/steps/introduction

https://www.wsj.com/articles/SB108249266648388235

https://www.wsj.com/articles/SB108249266648388235

https://gizmodo.com/exclusive-heres-the-full-10-page-anti-diversity-screed-1797564320

https://gizmodo.com/exclusive-heres-the-full-10-page-anti-diversity-screed-1797564320

https://www.nytimes.com/2017/08/08/technology/google-engineer-fired-gender-memo.html



https://www.wired.com/story/the-pernicious-science-of-james-damores-google-memo



8What’s Next?

The greatest enemy of learning is knowing.—John Maxwell1

By now it should be clear that psychological safety is foundational tobuilding a learning organization. Organizations that seek to stay rele-vant through continuous learning and agile execution must cultivatea fearless environment that encourages speaking up. In any companythat thrives in our complex and uncertain world, leaders must be lis-tening intently, with a deep understanding that people are both thesensors who pick up signals that change is necessary and the sourceof creative new ideas to test and implement.

Continuous Renewal

We’ve seen that leaders have many tools at their disposal to create andnurture a workplace conducive to learning, innovation, and growth.

187


Through their words and actions, and through designing systemsthat engage people in useful conversations, leaders help bring fearlessworkplaces into being. We’ve also seen that psychological safety isfragile and needs continuous renewal. When we set out to createorganizations where people can bring their full selves to work, we’reswimming upstream against deeply ingrained psychological currents.

The basic asymmetry of the psychological and societal forcesfavoring silence over voice, or self-protection over self-expression,will always be with us. But the rewards of voice and silence are alsoasymmetrical. Self-protection remains a hollow victory compared tothe fulfillment that comes from actively serving an inspiring purposeand being a part of a team that’s able to accomplish an ambitiousgoal. It’s the difference between playing not to lose and playing to win.2

Playing not to lose is a mindset that focuses, consciously or not,on protecting against the downside; playing to win, in contrast, isfocused on the upside, seeks opportunity, and necessarily takes risks.When we’re playing not to lose, we play it safe.

Stop to consider which mindset is in charge when you’re at work.How often do you find yourself truly playing to win? It can be chal-lenging to make this shift, because when you play not to lose, you’relikely to succeed (in not losing). But you miss opportunities to grow,to innovate, and to experience a deeper sense of fulfillment. Whenyou make up your mind to play to win, the rules change. Yes, youmight fall flat on your face publicly sometimes. But you also willbecome more able to contribute to something that makes a differencein the world.3 Perhaps the best way to experience psychological safetyis to act as if you have it already. See what happens! The chances areyou’ll be creating a safer and more energizing environment for thosearound you as well. Exercising a small act of leadership.

Leadership is a vital force in making it possible for peopleand organizations to overcome the inherent barriers to voice andengagement, so as to gain the emotional and practical rewards of fullyparticipating in an inspiring shared mission. As noted in Chapter 7,leadership is not constrained to the top of an organization but rathercan be exercised at all levels. Leadership at its core is about harnessing

What’s Next? 189

others’ efforts to achieve something no one can achieve alone. It’sabout helping people go as far as they can with the talents andskills they have. As I hope this book convinces, substituting candorfor silence and engagement for fear are essential responsibilities forleaders today.

The stories throughout this book capture specific moments intime in organizations around the world. We saw organizations where alack of psychological safety contributed to significant business failuresas well as to human physical harm. A contrasting set of cases providedglimpses into workplaces characterized by candor and engagement.These cases showcased unusual workplaces where failure was not stig-matized, and people understood that risk taking and learning wereintegral to how work gets done. Nonetheless, it’s not easy to pre-dict what will happen next in any of these organizations. Nor is itaccurate to characterize the entire organizations based on the indi-viduals and groups portrayed in these cases. Psychological safety isdynamic. A workplace with unusual candor may shift in the face ofnew leaders or new circumstances. One dominated by fearful silencealso can change, becoming conducive to thoughtful input and delib-erative decision-making. Often such shifts happen as the result of adeliberate effort to learn from an organization’s painful past failures.A few, merely illustrative, examples follow.

Deliberative Decision-Making

Recall Nokia, the Finnish company with centuries of contributionto its nation’s GDP and identity. Its downfall, as we saw in Chapter 3,had to do with a dance of fear between senior executives and engi-neers. Corporate headquarters didn’t want to hear the bad news thatSymbian, Nokia’s operating system, was about to become obsolete,outperformed by Apple’s iOS and Google’s Android platforms. Theengineers, whose antennae were tuned to what was coming from Sil-icon Valley, were afraid to break the news to their superiors; theirattempts to speak up seemed routinely silenced from above.


Fast forward to 2013. Nokia’s strategic comeback was to divest itsmobile phone business and focus instead on manufacturing networkequipment and software, acquisitions and partnerships, patentlicenses, and the Internet of Things. In this dramatic shift, Nokialeaders had to have sustained, thoughtful conversations to maketough choices. For this to work, they needed to divest themselvesof their previous dance-of-fear moves and embrace the candor ofPixar’s Braintrust. They needed to begin from Eileen Fisher’s placeof not-knowing.

Professors Timo Vuori at Alto University in Finland and QuyHuy at INSEAD (originally an acronym for the French “InstitutEuropéen d’Administration des Affaires”) conducted 190 interviewsat Nokia, including 9 board members and 19 top managers, to findout how the company’s executives, many of them newly installed,managed to work together to make these strategic decisions. Oneof the first things the board did was to establish rules for discussionthat included some of the basic norms of psychological safety – forexample, that everyone’s voice must be heard and respected. How-ever, it wasn’t enough to merely draw up a new set of conversationalrules. Habits and culture do not change overnight.

A board member told the researchers that “after he had made ahostile comment to a top manager, the chairman made him apologizeto the top manager in the next meeting.”4 In other words, the newchairman had to consciously reinforce the rules to increase trust betweenindividuals and in general create a culture where people could feelpsychologically safe to speak openly. This was no exercise in play-ground civility, no effort to “play nice.” In contrast, the future of thecompany depended on fearless, creative input and open discussionfrom its leaders. And apparently, that’s what they were able to do. Asa top manager told the researchers, “with [the new chairman] we arenot afraid, we don’t have to think about what we say too much. It’spretty easy to discuss things with him and throw in ideas and thinkout loud.”5 Over a period of years, that process – of throwing in ideas,and thinking out loud together – yielded new perspectives, strategies,data collections, options, scenario analysis, and so on. Like Pixar’s

What’s Next? 191

filmmakers, Nokia managers were able to reject strategies they foundunusable and continue to brainstorm new ones until their deliberativedecision-making process came up with a strategy the board and topmanagement felt was right.

Hearing the Sounds of Silence

We must be realistic about the fact that “driving fear out” of anyorganization, as W. Edwards Deming (the father of total quality man-agement who helped transform manufacturing practices around theworld) put it, will be a journey.6 We don’t have a magic wand to makepsychological safety happen overnight, but by committing to the aspi-ration to build it, one conversation at a time, leaders take the first stepof a perpetual journey toward building and nurturing organizationsthat can innovate and thrive in the knowledge economy.

In the decade following the Columbia shuttle’s final mission, I hadbeen using a powerful multimedia case study that my colleagues and Ideveloped from public sources to teach in leadership programs at Har-vard Business School and around the world.7 One day, in 2012, myoffice phone rang. To my surprise, the caller announced that he wasfrom NASA. “We know what you’re doing,” he said. As I swallowed,he continued, “and we think it’s great.” The caller was Ed Rogers,and he was the Chief Knowledge Officer at NASA’s Goddard SpaceFlight Center. This was a striking moment for me. In our research, wehad had the opportunity to interview Diane Vaughn, the sociologistand Columbia University professor known for writing the definitivebook on the ill-fated Challenger launch decision of 1986.8 Back inthe early 1990s, Vaughn’s book had unexpectedly catapulted her intothe limelight, and she received many invitations to speak to businessexecutives and policy makers. As she humorously put it, “everyonecalled,” and she went on to name several top corporations, as well asthe US Congress. Vaughn laughed, “my high school boyfriend evencalled! But NASA never called . . . ” So the simple fact of “NASAcalling,” to me, signaled a shift.


Rogers volunteered to visit my next on-campus class, bringingRodney Rocha with him. Later, he did just that, and it was a power-ful experience for the students and for me. Rogers went on to explainthat he was organizing a day-long workshop, called the Sounds ofSilence, and he wanted me to speak. (Of course, I cleared my sched-ule.) With three outside speakers and eight senior insiders, the work-shop discussion ranged from the need to create a “no fear” federalworkplace to the terrible dangers of silence to the power of studyingnear misses to avoid catastrophes.

Held in a large and packed auditorium, the workshop was onlyone of the many ways that NASA was taking seriously the desireto alter its culture. Several new structures had been implemented,including a formal dissenting-opinion mechanism to lower the barto speaking up, a new safety reporting system, and an ombudsmanprogram. New awards were created, like the “Lean Forward, FailSmart Award” to recognize that in “a culture of innovation, fail-ure is seen as merely a stepping stone to success.”9 Insiders wrotea detailed case study on Columbia and were teaching it throughoutthe agency, as well as making it publicly available.10 This was a farcry from the organization I had studied, where managers had beenfiercely committed to ensuring that no bad news escaped the organi-zation walls. Rogers emphasized, in our personal conversations, that“communication is key to our success” and that a “listening culture”was as important as a speaking up culture, connecting to our discus-sion in Chapter 4 of Roger Boisjoly’s unsuccessful efforts to speak up.“Communication involves transmitting and receiving,” he explained.Rogers called Christopher Scolese, the then-new director of NASA’sGoddard Space Flight Center, “the finest leader I’ve ever worked for.”When I asked why, he explained it was because “he cares about peo-ple. He has a strategic perspective. He cares about Space and NASA”(as a whole, rather than favoring a given facility). He went on to talkabout how much Scolese demonstrated respect for, and interest, inothers’ contributions.

I tell this story not as proof of culture change but rather as an illus-tration of the many ways in which organizations are waking up to the

What’s Next? 193

need for psychological safety for achieving excellence in a complex,ambiguous world.

When Humor Isn’t Funny

“Can you stay late today to work on the project with me?” asked afemale Uber employee to her male colleague.

“I will if you’ll sleep with me.” And then, after a beat. “Justkidding.”

It sounds like a bad joke. After Harvard Business School Pro-fessor Frances Frei began a nine-month tenure at Uber as an exec-utive on loan to change the culture, she describes this incident asone of many that belong to a category she labels “Just Kidding.”11

As she explained, if someone felt the need to add the tagline “justkidding,” after a comment, it probably meant the person knew thecomment was at risk of being unwelcome or inappropriate. Frei’sinsights into what went wrong at Uber to create the toxic culturedescribed in Chapter 4, along with the measures she initiated tohelp after the onslaught of negative publicity, show how psycho-logical safety can be created in organizations that had been blatantlyunsafe.

Frei points out that people needed new skills to respond tothese “just kidding” moments – especially until the time when suchmoments would become unacceptable in the organization’s culture.Her suggested response to the exchange described above was, “Wow,that felt super-inappropriate. Can we have a do-over?”12 Ideally,new responses would percolate throughout the organization, untileventually the “just kidders” would begin speaking appropriately andinclusively. These kind of “bottom-up” changes – enacted by peoplewithout formal power throughout a company – are most effectivewhen accompanied by clear cultural directives set by leadership.When Uber’s new CEO, Dara Khosrowshahi, came on board inAugust 2017, one of his first actions was to solicit employee inputfor a new set of company values. Signaling a shift to integrity from


the company’s previously valued “toe-stepping,” Number 4 nowreads, “Do the Right Thing. Period.”13

Uber’s hypergrowth as a ride-hailing company meant that man-agers were quickly getting promoted to positions beyond their capa-bility. They did not have the experience or training to lead effectively.As Khosrowshahi put it, “we were probably trading off doing theright thing for growth, and thinking about competition maybe a bittoo aggressively, and some of those things were mistakes.”14 In keep-ing with the more psychologically safe culture his leadership portends,Khosrowshahi explains, “mistakes themselves are not a bad thing. Thequestion is, do you learn from those mistakes?”15

Some behaviors contributing to a climate of fear can be remediedby simple rule changes. For example, Frei recounts that when shefirst arrived, common behavior during meetings with senior teammembers included everyone on his or her phone – texting oneanother about the meeting!16 It was the equivalent of being whis-pered about behind your back in high school and obviously loweredwhatever psychological safety might be in the room. Contrast thisbehavior with Dalio’s injunction for transparency throughout theorganization and his rather unattractive term “slimy weasel” forthose who might violate the transparency norm. What’s more, thebehavior was indicative that no one felt safe enough to speak up orstate honestly to the group what was on his or her mind. As LianeHornsey, Uber’s new head of Human Resources, put it, “there wasno sense of trust, no sense of ‘We’re building this together.’”17 Inthis case, the remedy was fairly straightforward: mandate that peopleput down their phones! Only then could people begin to look up,listen, and collaborate. In other words, the journey out of fear andtoward psychological safety had begun.

Recall, also, from Chapter 4 that it was Susan Fowler’s act ofspeaking up, early in the #MeToo movement, that first exposedUber’s culture of fear. While this is not the place to trace thefascinating trajectories and subtle cultural shifts that MeToo spawned,it’s worth mentioning that the sheer act of speaking up eventuallydid lead to actionable change, and not only at Uber. For example,

What’s Next? 195

the National Women’s Law Center founded a “Time’s Up” LegalDefense Fund to enable more women to come forward and beassured of legal support.18

Change is possible. It may be hard work, but cultures can, andmust, change if organizations are to thrive in a knowledge-intensiveworld. The hard, rewarding work of creating an environment wherepeople can bring their full selves to work can be supported by outsidefacilitators and coaches, if desired. As we have seen in Chapter 7, anetwork of internal coaches can also be created to work with individ-uals and teams to build and restore psychological safety, as was doneat Google with the g2g network. Of course, these approaches alsocan supplement each other. To help with this journey, next I offer afew additional thoughts triggered by questions from people workingin organizations around the world.

Psychological Safety FAQs

Over the past 20 years I have led many leadership programs in businessand public-sector organizations. Although myriad topics are coveredin these sessions, psychological safety always plays a crucial role andoften generates questions from participants. And so I want to providesome of the answers I’ve offered these audiences, with the hope thatthey will address your questions as well.

Can You Have Too Much Psychological Safety?

This is probably the question I am asked most often. When I talkwith people in companies, hospitals, government agencies, andnon-governmental organizations (NGOs) around the world, theyintuitively recognize the need for psychological safety to allow learn-ing and innovation to take hold. Yet many worry, understandably,that by releasing the brakes on voice, people will just plain talk toomuch. Uninformed, unhelpful comments will derail projects. Goodideas will get lost in a sea of chatter. People will be sloppy.


My short answer? No. I don’t think you can have too muchpsychological safety. I do think, however, that you can have notenough discipline. Psychological safety is about reducing interpersonalfear. Making it less heroic to ask a question or admit an error.It doesn’t mean you automatically have a good strategy for gettingthe work done. It also doesn’t mean your employees are sufficientlymotivated or well-trained.

People asking this question are often wondering where the levelof psychological safety should be set to have the best results. I havesympathy for the concerns that motivate them to ask. But I want tosuggest a solution that doesn’t involve figuring out the optimal levelof interpersonal fear.

My view is that interpersonal fear is never particularly helpful atwork. While it can be motivating to be afraid of missing a deadline,afraid of failing the customer, or afraid of the prowess of the compe-tition, being afraid of one’s boss or colleagues is not only unhelpfulin an environment where technologies, customers and solutions arein flux, it’s downright risky. The potential costs of not speaking up ina timely way are simply too great.

What today’s leaders need to understand is that people sponta-neously set an invisible threshold that governs when they speak upand what they speak up about. The problem is that most peopleset the level too high when they’re at work. We err on the side ofholding back information or questions – even when we believe theymight matter, that they might have the potential to add value. Infact, it’s extremely rare to find people erring on the side of voice.I’m not saying that it isn’t possible for the threshold to be set toolow, thereby unleashing all kinds of unhelpful or inappropriate voice,but rather that this occurs less often than one might expect. Even so,this particular risk (of excessive voice) is not best addressed by reduc-ing psychological safety but rather by providing feedback to give thespeaker insight into the impact he or she had.

I do not see psychological safety as a panacea. Far from it. Psy-chological safety is only one of many factors needed for success in themodern economy. As discussed in Chapter 2, psychological safety is

What’s Next? 197

better thought of as an enabler that allows other factors like moti-vation, confidence, or diversity to have the desired effects on workoutcomes. Psychological safety makes it possible for other drivers ofsuccess (talent, ingenuity, diversity of thought) to be expressed in waysthat influence how work gets done.

Won’t Having a Psychologically Safe Workplace Take Too MuchTime?

This question – along with the very similar, “How will we get any-thing done if people are always talking?” – clearly overlaps with thequestion about having too much psychological safety but adds explicitattention to time and efficiency. And time and efficiency are suchimportant issues in the modern organization that it’s worth stoppingto consider them directly.

Mirroring the concern about a low threshold for voice is the con-cern that meetings will go on and on because everyone must have hisor her say. This confuses psychological safety with bad process. Justas discipline is needed for excellence in general, managing effectivemeetings – for decision-making, problem solving, or mere report-ing – is a matter of skill, discipline, and smart process design. Thereare many good sources of advice on how to have effective, efficientmeetings, complete with practical tools for ensuring input withoutunleashing chaos.19 And none of these tools is at odds with establish-ing a climate of candor, where people are able to focus on the taskrather than on face-saving and self-protection.

To take it a step further, I argue that psychological safety cansave rather than consume time. Although not a hard and fast rule,psychological safety can be a source of efficiency. For instance, I’vestudied senior management teams in which a lack of psychologicalsafety contributed to long-winded conversations (indirect statements,with veiled criticisms and personal innuendo, take longer than can-did ones), elongated meetings, and an inability to come to a resolu-tion about crucial strategic issues.20 Decisions that could have been


resolved in hours stretched over months.21 In short, the lack of psy-chological safety can be deeply inefficient, in addition to being inef-fective. Also recall from Chapter 3 how a lack of psychological safetyat the Federal Reserve Bank of New York led issues to be discussedat length without resolution. By way of contrast, I have worked withteams in which clear process combined with direct and open dialogueto produce efficient, smart conversations and clear decisions.

You Advocate a Psychologically Safe Workplace. Does That MeanWe Have to Be Transparent About Everything?

To say that psychological safety can’t be too high is not the same assaying more transparency is always better. Different situations likelycall for different levels of transparency. In the surgical operatingroom, I’d venture to say that full transparency is excellent practice.Please share any observations you have! If they are wrong or unhelp-ful, I hope (and expect) others to respond with appreciation andtransparency to that effect as well. But there are times where it simplyisn’t all that helpful to share each and every one of your workplacethoughts – for example, about someone’s attire or presentation style.I think reasonable people can disagree about whether Ray Dalio’saggressive transparency would work in their own companies orindustries. Decisions about what aspects of personal growth andfeedback are fair game in your organization, for instance, can bethoughtfully made.

But very few of us would voluntarily seek to work in an envi-ronment where we don’t feel psychologically safe. So why should wewant this for others? None of us does our best work when distractedby mild worries about how our colleagues or bosses will react if wespeak up with a work-relevant idea or question. The goal is to figureout how much transparency, and about what, you need (and this willprobably take some experimentation to get it right) to do the best pos-sible work in your company or in your industry. In the meantime, it’s

What’s Next? 199

important to keep working hard to make sure people are not holdingback on work-relevant thoughts due to fear of embarrassment.

I’m All for Psychological Safety at Work, but I’m Not the Boss. IsThere Anything I Can Do?

While it is true that bosses – team leaders, surgeons, departmentheads, etc. – play an outsized role in shaping expectations and behav-iors in the workplace, anyone can help create psychological safety.Sometimes, all you have to do is ask a good question. This is trulya great place to start. A good question is one motivated by genuinecuriosity or by a desire to give someone a voice. Questions cry outfor answers; they create a vacuum that serves as a voice opportunityfor someone. Especially when a question is directed at an individual(and expressed in a way that conveys curiosity), a small safe zone isautomatically created. By asking a question, you have conveyed, “I aminterested in what you have to say.” In so doing, you have created asafe space that helps one or more others to offer their thinking.

Additionally, with or without having asked a question, you cancreate psychological safety by choosing to listen actively to what peo-ple say and by responding with interest, building on their ideas, orgiving feedback. True listening conveys respect – and in subtle butpowerful ways reinforces the idea that a person’s full self is welcomehere. Note that this does not mean you have to agree with what some-one said. You don’t even have to like it. But you do have to appreciatethe effort it took for her to say it.

Saying things to frame the challenge you see ahead is anotherhelpful practice. Reminding people of what the team is upagainst – for example, by talking about how the work is uncertain,challenging, or interdependent – helps paint reality in ways thatemphasize that no one is supposed to have all the answers. Thislowers the hurdle for speaking up. It reminds people that their inputis welcome – because it’s needed.


Finally, I would like to suggest a few simple, uncommon, powerfulphrases that anyone can utter to make the workplace feel just a tinybit more psychologically safe:

I don’t know.I need help.I made a mistake.I’m sorry.

Each of these is an expression of vulnerability. By being willing toacknowledge that you are a fallible human being, you give permissionto others to do likewise. Removing your mask helps others removetheirs. Of course, this means acting as if you feel psychologically safe,even if you might not be fully there yet. Sometimes, you have to takean interpersonal risk to lower interpersonal risk.

Similarly powerful in shaping the climate even if you are not theboss are words of interest and availability. For example, most of us facemany opportunities to say things like these:

What can I do to help?What are you up against?What are your concerns?

The personal challenge for all of us lies in remembering, in themoment, to be vulnerable, as well as to be interested and available. Todo this you will have to take on the small interpersonal risk that yourattempts may be ignored or, worse, rebuffed. But in my experience,the odds are low. Assuming a modest level of good will in your organi-zation, most of the time your colleagues will respond well to genuineexpressions of vulnerability and interest. So, give it a try. Pause; lookaround. Whom can you invite into the safe space for learning andcontributing to the shared goal? See what happens.

What I hope is clear at this point is that you don’t have to be theboss to be a leader. The leader’s job is to create and nurture the culturewe all need to do our best work. And so anytime you play a role indoing that, you are exercising leadership.

What’s Next? 201

What’s the Relationship Between Psychological Safety and Diversity,Inclusion, and Belonging?

This question, increasingly common, almost answers itself. So let mestart by saying that a workplace that is truly characterized by inclusionand belonging is a psychologically safe workplace. Today we knowthat although diversity can be created through deliberate hiring prac-tices, inclusion does not automatically follow. To begin with, all hiresmay not find themselves included in important decisions and dis-cussions. Going deeper, a diverse workforce doesn’t guarantee thateveryone feels a sense of belonging. For instance, when no one at thetop of the organization looks like you, it can make it harder for youto feel you belong.

Each of these three terms represents a goal to be achieved. Thegoals range from the relatively objective (workforce diversity) to thehighly-subjective (do I feel that I belong here?). Inclusion is morelikely to function well with psychological safety because diverse per-spectives are more likely to be heard. But it is not easy to feel a senseof belonging if one feels psychologically unsafe. As goal achievementbecomes more subjective, psychological safety becomes more valu-able; there is no way to know if you’re achieving the goal withoutbroad input from people in different groups.

Although I’ve been studying psychological safety for more than20 years, it’s only recently that I’ve been asked to consider its relation-ship to diversity, inclusion and belonging at work. As issues related todiversity at work have moved to the forefront of the agenda in organi-zations aspiring to excellence, in response to current news and othersocietal factors, I have begun to consider the central role that psycho-logical safety plays and can play. A fearless organization realizes thebenefits of diversity by fostering greater inclusion and belonging. Arecent tidal wave of harassment claims highlights the costs of failingto create a psychologically safe workplace for women.

At the same time, a singular focus on psychological safety is not astrategy for building diversity, inclusion, and belonging. These inter-related goals must go hand in hand. Great organizations will continue


to attract, hire, and retain a diverse workforce because their leadersunderstand that that is where good ideas come from, and talentedapplicants will be drawn to work for those organizations. These lead-ers also recognize that hiring for diversity is not enough. They alsomust care about whether or not employees can bring their full selvesto work – whether they can belong in the fullest sense to the commu-nity inside the organization. In short, leaders who care about diversitymust care about psychological safety as well. It’s that extra ingredient,as discussed in Chapter 2, that allows diversity to be leveraged.

Is Psychological Safety About Whistle-blowing?

Whistle-blowers are organizational insiders who expose wrongdoingthey’ve observed (and often tried unsuccessfully to alter) by reachingout to external authorities or to the press. By reporting activity thatmay be illegal or unethical – from fraud and corruption to publicsafety or national security risks – whistle-blowers take on the risk ofretaliation from those they accuse of wrongdoing. They demonstratecourage. Whistle-blowing, however, is not a reflection of psycholog-ical safety but rather an indication of its absence. In companies withpsychological safety, whistle-blowing should not be needed becauseemployee concerns will be expressed, heard, and considered.

Speaking up and listening, which go hand in hand in a healthyorganizational culture, reinforce standards of professionalism andintegrity. When valid concerns are expressed, changes can be madein a timely way. Of course, it is possible for an employee to fail tofully explore the options for internal discussion of concerns – andblow the whistle prematurely. It is possible even in a climate whereinternal learning would have been welcomed. By and large, however,in a psychologically safe climate, an employee’s first instinct is not togo outside the organization to report perceived wrongdoing.

It’s in any organization’s best interest to foster an environmentthat facilitates speaking up internally rather than to leave people feel-ing they have no choice but to go outside the organization with their

What’s Next? 203

concerns. It is far better to respond to early signals that there may beproblems, so as to address them through meaningful changes, ratherthan to end up with visible public reports of wrongdoing or harm. Tomake this process easier, ombudspersons can help internal voices beexpressed in a specific context that is designed to be safe. Ombudsper-sons offer confidentiality and support for those with ethical and safetyissues and also can trigger a process of making necessary changes inan organization to mitigate concerns through genuine improvement.

What About Those Successful Companies Run by ArrogantTop-down Dictators Who Don’t Listen to Anyone and SometimesReduce People to Tears?

I’ve been asked this question more times than I can count. It comesfrom smart people who step back and think, “wait a minute! Ifpsychological safety promotes excellence in an uncertain world, howcome I can point to counterexamples – that is, to stories of extremelysuccessful companies that seem very much to lack psychologicalsafety?”

I want to respond in two parts to this important question. First,let’s remember the fallacy of sampling on the dependent variable, aclassic error in research. In other words, the success in question mayin fact be explained by the leader’s arrogance and top-down approach;conversely, it may be explained by other factors: good timing, a mar-ket vacuum, a genius idea, or even just plain luck.

Second, there’s a lack of ready access to counterfactual data. Inother words, we don’t know what would have happened in the suc-cessful company had more of the talent it contained been put to gooduse. We simply have a case of low psychological safety and high com-pany performance for a particular period of time. The first variablemay, or may not, explain the second. It’s possible that the companywould have failed had more people felt able to express their ideas; itis also possible, and perhaps even likely, that the upside for the com-pany could have been even higher than it was. Finally, the company’s


success may ultimately prove to be short lived because it is at risk offailing to make necessary changes when early warnings of the suc-cessful formula’s wane in a changing marketplace are not heard orheeded. Not to mention the possibility that smart, talented peoplewho are not being heard may leave for other opportunities.

Finally, the companies motivating thoughtful people to ask thisquestion may be one of those rare cases of a genius at the helm whoindeed has all the answers. Steve Jobs comes to mind. To the extentthat you feel you fall into that category – a rare genius who has perfectpitch in terms of what the market wants – you may be able to specifythe work that needs to be done clearly enough for others to merelyexecute. In that case, go for it! You will be able to forfeit seeking or lis-tening to the input of those who work below you in the organization.Henry Ford, after all, was said to have complained, “why is it everytime I ask for a pair of hands, they come with a brain attached?”22

But for the rest of us, I wouldn’t recommend that approach. Few busi-ness leaders today can afford to squander the brainpower available intheir companies. At the very least most of us need an honest soundingboard. But better yet, we need people to bring their ideas to work tohelp us create better products and a better organization.

Help! My Colleague Is Bringing His True Self to Work and It’sDriving Me Crazy!

I think most of us can empathize with this one. Perhaps there are peo-ple we wish felt a little less psychologically safe at work so that they’dstop expressing themselves! Tempting as it is to want to solve this kindof problem with a sprinkle of interpersonal fear, in the long run it’s nota productive solution. The most important reason is this: a colleaguewho is not being helpful and productive needs – and deserves – ourfeedback. Psychological safety doesn’t guarantee effectiveness. It justmakes it easier to find out what people have to offer. Sometimes,that’s a happy surprise. But when people feel able to express them-selves, and you find that what they say is not adding value, then you

What’s Next? 205

have a responsibility to help. To coach. And even though it’s not funto give people that kind of feedback, it’s better to know that someoneis in need of it than to remain in the dark. Moreover, it’s only fair tolet your colleagues know that the impact they’re having is not whatthey’re hoping it is.

Help! I’ve Started Bringing My Whole Self to Work and No OneLikes Me (Anymore)!

I suspect if you’re reading this book, the odds of the situation impliedby this question are low because you’re probably thoughtful, curious,and intent upon making your organization a better place. And, if so,others similarly intent on learning are likely to welcome hearing whatyou have to say. Nonetheless, let’s consider the two basic possibilities.One is that your ideas are just not getting the positive reception youhad expected. In this case, just as others deserve your feedback, youdeserve others’ feedback. Consider this a learning opportunity – anopportunity to find out what it is about what you’re saying or doingthat is falling short of the mark.

The other possibility is that you’re learning something about yourcolleagues or your organization that suggests that you’re not in a jobthat is a good fit with your personal values and goals. If you’re sharingsincere concerns, ideas, and ambitions for the organization, and othersare indifferent, turned off, or disparaging, then you may want to lookfor an opportunity where you will have colleagues who appreciateyour commitment to making a positive difference at work.

What Advice Would You Give to the People Who Reportto Managers Who Can’t or Won’t Change?

I would start by recommending curiosity, compassion, and commit-ment. You see, we all need to remind ourselves, whether we’re theboss or not, that no one can actually change another person. We can’t


force people to change how they think and act, even when we haveformal responsibility over them – let alone when we don’t. We canonly influence them. The good news is that anyone can influence oth-ers by modeling the three Cs listed above. Start with curiosity, whichleads us to ask questions. When we ask genuine questions, people feelthey matter (whether boss, peer, or subordinate), especially when welisten and respond thoughtfully to their answers. (Meanwhile, we justmight learn something, which can also be helpful).

Compassion is the self-discipline to imagine and remember thateveryone faces hurdles. All people are up against something – smallor large – that frustrates them or keeps them up at night. The moreyou understand what others are up against, the more you sponta-neously do things that help build work relationships that are resilientand strong, as needed for getting the work done. Finally, commitmentmatters because if you demonstrate your dedication to achieving theorganization’s goals, it can be contagious. When people, especiallymanagers, believe you really care about the work, they’ll also cut yousome slack.

A related, oft-raised issue is captured in the following comment:“but the people above me don’t do this, so I’m stuck.” With greatempathy, my response is first to let people know how widespread thisexperience is and that I recognize how frustrating it feels. Then, I goon to point out that people have a natural tendency to look up – tolook in the direction of the managers above us in the hierarchy. Wehave to train ourselves to look down and across instead. As noted ear-lier, each of us can shape the climate in which we work in small ways.Creating a pocket of excellence, candor, and learning in your groupis worthwhile, no matter what those above you are doing. It maybe contagious! As an aside, I’ve been struck by how many times thepeople articulating this concern are near the very top of enormouscompanies. They may be among the top 200 managers in a globalcorporation, and yet their natural tendency is still to look upwardand bemoan their powerlessness. And so I also remind them gentlythat there are a great many more people looking up and pointing tothem as the problem than there are above them.

What’s Next? 207

Can Anyone Learn to Be a Successful Leader of Psychological Safety?

My view is that, yes, most people can learn. And that includeslearning to better understand the positive and negative effects thatone’s mindset and behavior is having on others. Most people wouldprefer to have positive rather than negative effects on others, andmost are also able to gain insight on how to do that, with trainingand coaching. Will some people be harder to help? Yes, of course.Narcissism, borderline personalities, low emotional intelligence, andother limitations will make it more difficult to behave in ways thatbuild psychological safety and, in some cases, impossible. Nonethe-less, there is very little downside to starting with an open mind aboutthe ability of anyone to change to become more effective. You mightwin, and you likely lose very little, with that open mind.

What About Cross-cultural Differences? Is It Possible to CreatePsychological Safety in China? In Japan? In [you name the countryhere]?

Many people believe that in some countries expecting employeesto speak up at work is simply unrealistic. Indeed, research showsthat workplace psychological safety is lower in countries with greater“power distance,” the extent to which a society accepts that poweris distributed unequally between high-status and low-status mem-bers.23 Trying to promote candor or error-reporting, for example,they claim, would be a fool’s errand in Japan. Of course, this impec-cable logic bumps up against the reality of the Toyota ProductionSystem – an approach to continuous improvement and flawless exe-cution that depends on every employee, up and down the hierarchy,to continuously, energetically, willingly point out errors! Is this typi-cal of the Japanese culture? No. Is it deeply embedded in the Toyotaculture? Yes.

In other words, it can be done.Of course, it’s not easy to create a culture like Toyota’s. But it is

worthwhile – if excellence and continuous improvement are goals of


your organization. And cultural differences in power distance doesmean that the job of creating psychological safety is harder in somecountries than others. Nonetheless, this does not make it any lessnecessary. If the work an organization does involves uncertainty, inter-dependence, or high stakes, success depends on creating some degreeof psychological safety. Without a willingness to speak up about prob-lems and errors, quality cannot improve. Without willingness to askfor help, employees will underperform. Without a willingness to chal-lenge a decision, organizations are at grave risk of preventable failures,both large and small. So roll up your sleeves; you have work to do! Itmay involve swimming upstream against cultural forces, but it can bedone. The good news is that, when done well, your efforts can createa powerful source of competitive advantage in a playing field whereaverage psychological safety is low.

What the Questions Reveal

In closing, I am sometimes struck by the anxiety people seem to feelabout creating psychologically safe organizations; perhaps we’re natu-rally comfortable living with the devil we know – organizations whereself-protection quietly crowds out much of the creativity, learning,or belonging that lies under the surface without our noticing. Andthe devil we don’t know – unusual workplaces where people can beand express themselves, confronting greater conflict and challenge butgreater fulfillment as well – awaits.

Tacking Upwind

If you set out to build psychological safety in your organization,it’s somewhat like setting sail on journey for which much is knownand much is unknown. Just as skippers and crew on a sailboat mustcommunicate and coordinate to stay the course facing shifting tidesand winds, you and your colleagues must do likewise. The sailing

What’s Next? 209

metaphor is apt as well because it’s impossible for a sailboat to headdirectly to an upwind mark (almost always set as the first destination ina regatta). The boat can head at a 45-degree angle off from the target,getting closer, and then “tacking” – switching to head at a 45-degreeangle on the other side. Zigzagging upwind in this manner, the boateventually arrives at its destination, having made large (tacks) andsmall (sail adjustments) pivots along the way.

You speak up about newborns’ need for prophylactic lung med-ication, comment on a weak plot twist in an animated film-in-progress, suggest clearance heights for forklifts, or advocate forphysical safety in a large South African mine. Zig left. Smooth sailingensues. Your superiors are too busy to listen, do not respond, tell youit can’t be done, pass you over for promotion. The wind leaves yoursail. If you happen to be the CEO of a mine, you can close the mineto make your point. Or ask a simple question that’s motivated by gen-uine curiosity. Zag right. Ask nurses if everything was as safe as theywould have liked. Assure miners that speaking up about safety issueswill not endanger their jobs. Admit you don’t know. Confess failure.Apologize. Call for help. Sailing will be smooth, at least for a while.

Creating psychological safety is a constant process of smallerand larger corrections that add up to forward progress. Like tackingupwind, you must zig right and then zag left and then right again,never able to head exactly where you want to go and never quiteknowing when the wind will change.

Endnotes

1. Maxwell, J. Beyond Talent: Become Someone Who Gets ExtraordinaryResults. Thomas Nelson, 2011. Print, pp. 184.

2. This dichotomy between seeking gains vs. avoiding losses has beencalled many things in different circles. In business, we talk about man-agers or companies “playing to win” vs. “playing not to lose.” Similarly,Daniel Kahneman and Amos Tversky spearheaded the field of behav-ioral economics partly through their research on “loss aversion,” theidea that the pain of a loss outweighs the pleasure of an equivalent gain.


In psychology, Columbia University Professor E. Tory Higgins distin-guished between individuals with a “promotion focus” vs. those with a“prevention focus” in describing what motivated people to make certaindecisions or take certain actions. And Stanford educational psycholo-gist Carol Dweck has written extensively about students with “fixedmindsets,” who believe they must avoid looking dumb, vs. those with“growth mindsets,” who are motivated by learning and improvement.Whatever one calls this dynamic, the verdict is clear: sustainable individ-ual, team, and organizational performance come from seeking to gain,not through fear of loss.

3. See Wilson, L. & Wilson, H. Play To Win!: Choosing Growth Over Fearin Work and Life. Revised ed., Bard Press, 2013. Print., for a truly usefulguide to making the mindset shift this entails.

4. Vuori, T. & Huy. Q. “How Nokia Embraced the Emotional Sideof Strategy.” Harvard Business Review. May 23, 2018. https://hbr.org/2018/05/how-nokia-embraced-the-emotional-side-of-strategyAccessed June 14, 2013.

5. Ibid.6. Deming, W. E. Out of the Crisis. Cambridge, MA: Massachusetts Insti-

tute of Technology, Center for Advanced Engineering Study, 1986.Print.

7. Interested readers can find the case study here: Bohmer, R.J., Edmond-son, A.C., & Roberto, M.A. Columbia’s Final Mission (MultimediaCase). Case Study. HBS No. 305-032. Boston, MA: Harvard BusinessSchool Publishing, 2005.

8. Vaughan, D. The Challenger Launch Decision: Risky Technology, Culture,and Deviance at NASA. Chicago, Illinois: University of Chicago Press,1996. Print.

9. See https://nasapeople.nasa.gov/awards/eligibility.htm Accessed June14, 2018.

10. The case study that was taught, as well as several other NASA case stud-ies, can be found here: https://www.nasa.gov/content/goddard-ocko-case-studies. Accessed June 1, 2018.

11. Frei described her experience at Uber in the following podcast: Har-vard Business School. “Fixing the Culture at Uber.” HBS After Hours.April 2, 2018. http://hbsafterhours.com/ep-6-fixing-the-culture-at-uber. Accessed June 1, 2018.

12. Ibid.

https://hbr.org/2018/05/how-nokia-embraced-the-emotional-side-of-strategy

https://hbr.org/2018/05/how-nokia-embraced-the-emotional-side-of-strategy

https://nasapeople.nasa.gov/awards/eligibility.htm

https://www.nasa.gov/content/goddard-ocko-case-studies

https://www.nasa.gov/content/goddard-ocko-case-studies

http://hbsafterhours.com/ep-6-fixing-the-culture-at-uber

http://hbsafterhours.com/ep-6-fixing-the-culture-at-uber

What’s Next? 211

13. Kohlatkar, S. “At Uber, a New CEO Shifts Gears.” The New Yorker.April 9, 2018. https://www.newyorker.com/magazine/2018/04/09/at-uber-a-new-ceo-shifts-gears Accessed June 14, 2018.

14. Ibid.15. Ibid.16. HBS After Hours, April 2, 2018, op cit.17. Kohlatkar, S. April 9, 2018, op cit.18. “TIME’S UP Legal Defense Fund.” NWLC. https://nwlc.org/times-

up-legal-defense-fund/ Accessed June 14, 2018.19. One of the best sources I know is Schwarz, R. The Skilled Facilitator: A

Comprehensive Resource for Consultants, Facilitators, Managers, Trainers, andCoaches. 2nd ed., San Francisco: Jossey-Bass, 2002. Print.

20. Edmondson, A.C. & Smith, D.M. “Too hot to handle? How to managerelationship conflict.” California Management Review 49.1 (2006): 6–31.

21. Edmondson, A.C. “The local and variegated nature of learning in orga-nizations.” Organization Science 13.2 (2002): 128–146.

22. Herrero, L. “The Last Thing I Need Is Creativity.” Leandro Herrero.April 14, 2014. https://leandroherrero.com/the-last-thing-i-need-is-creativity/ Accessed June 14, 2018.

23. For early research on power distance, see: Hofstede G. Culture’s Conse-quences: International Differences in Work-related Values. Beverly Hills, CA:Sage, 1999. Print. For studies that have found differences in psycholog-ical safety between high vs. low power distance groups, see:◾ Anicich, E.M., Swaab, R.I., & Galinsky, A.D. “Hierarchical Cul-

tural Values Predict Success and Mortality in High-Stakes Teams.”Proceedings of the National Academy of Sciences 112.5 (2015): 1338–43.

◾ Hu, J., Erdogan, B., Jiang, K., Bauer, T.N., & Liu, S. “Leader Humil-ity and Team Creativity: The Role of Team Information Sharing,Psychological Safety, and Power Distance.” Journal of Applied Psy-chology 103.3 (2017):313–23.

https://www.newyorker.com/magazine/2018/04/09/at-uber-a-new-ceo-shifts-gears

https://www.newyorker.com/magazine/2018/04/09/at-uber-a-new-ceo-shifts-gears

https://nwlc.org/times-up-legal-defense-fund

https://nwlc.org/times-up-legal-defense-fund

https://leandroherrero.com/the-last-thing-i-need-is-creativity

https://leandroherrero.com/the-last-thing-i-need-is-creativity

Appendix:Variations in surveymeasures to IllustrateRobustness ofPsychological Safety

Source Survey ItemsCronbach’sAlpha

Garvin,Edmondson, &Gino (2008)1

1. In this unit, it is easy to speakup about what is on your mind.

2. If you make a mistake in thisunit, it is often held againstyou. (R)

3. People in this unit are usuallycomfortable talking aboutproblems and disagreements.

.94

(Continued)

213

214 Appendix


.

4. People in this unit are eager toshare information about whatdoesn’t work as well as to shareinformation about what doeswork.

5. Keeping your cards close toyour chest is the best way to getahead in this unit. (R)

Tucker,Nembhard, &Edmondson,ManagementScience (2007)2

1. People in this unit arecomfortable checking witheach other if they havequestions about the right wayto do something.

2. The people in our unit valueothers’ unique skills andtalents.

3. Members of this NICU areable to bring up problems andtough issues.”

.74

Nembhard &Edmondson(2006)3

1. People in this unit arecomfortable checking witheach other if they havequestions about the right wayto do something.

2. Members of this NICU areable to bring up problems andtough issues.

3. If you make a mistake in thisunit, it is often held againstyou.

4. It is easy to ask other membersof this unit for help.

.73

Appendix 215


Edmondson(1999)4

1. If you make a mistake on thisteam, it is often held againstyou. (R)

2. Members of this team are ableto bring up problems andtough issues.

3. People on this team sometimesreject others for beingdifferent. (R)

4. It is safe to take a risk on thisteam.

5. It is difficult to ask othermembers of this team forhelp. (R)

6. No one on this team woulddeliberately act in a way thatundermines my efforts.

7. Working with members of thisteam, my unique skills andtalents are valued and utilized.

.82

Endnotes

1. Garvin, D. Edmondson, A., & Gino, F. “Is yours a learning organiza-tion?” Harvard Business Review (March 2008): 109–116.

2. Tucker, A.L., Nembhard, I.M., & Edmondson, A.C. “Implementingnew practices: An empirical study of organizational learning in hospitalintensive care units.” Management Science 53.6 (2007): 894–907.

3. Nembhard, I.M. & Edmondson A.C. “Making it safe: The effects ofleader inclusiveness and professional status on psychological safety andimprovement efforts in health care teams.” Journal of OrganizationalBehavior 27.7 (2006): 941–966.


Acknowledgments

Many have contributed to my research on psychological safety in thequarter century since I stumbled into the phenomenon by accident.First, there are the managers, nurses, physicians, engineers, frontlineassociates, CEOs, and other employees in the many organizationsthat opened their doors to this university researcher. I am gratefulfor their willingness to be interviewed and studied; their generouscontributions of time and insight made the work summarized inthis book possible. I also thank the Division of Research at HarvardBusiness School for generous financial support that funded thisresearch. I have been gratified in recent years by the dozens of bothnew and experienced researchers who have picked up on the conceptof psychological safety to include it in their studies, adding valuablediscoveries to the growing literature on this topic; their diverse,creative, rigorous research lends immense support to the argumentthat psychological safety matters for excellence in organizationsaround the world.

I am especially grateful to Jeanenne Ray at Wiley for herconfidence in my work and for her patience as I sailed right pastour original deadline. Patrick Healy provided invaluable researchassistance that contributed to the quality and depth of the evidenceI can offer to readers. In particular, he conducted literature reviewsof both academic and practitioner writings on psychological safety,painstakingly reading and making notes on hundreds of articles. Heidentified numerous case studies that helped bring these ideas to life.

217

218 Acknowledgments

His suggestions, edits, and enthusiasm for the topic truly contributedto making this a better book. Pat also took on the thankless tasksof managing references, permissions, and other endless details thatgo into a project like this with skill, precision, and remarkablegood cheer. I received insightful feedback at different points in thewriting process from three brilliant friends – Roger Martin, SusanSalter Reynolds, and Paul Verdin – that made crucial improvementspossible. Sara Nicholson provided essential help with proofing, withher usual level of extraordinary competence.

Of the many people who contributed to getting this book intoits final shape, Karen Propp is by far the most important. I am deeplygrateful to been able to work with her on this project. Without herperceptive questions, insights, ideas, stories, and well-honed skills as awriter and editor, this book would never have been finished. I thinkit’s fair to say that Karen, Pat, and I had fun teaming up – identifyingthe cases and ideas that made it into the final draft, along with thosethat didn’t. I hope you will find our choices to have been good onesfor capturing the richness and diversity of the settings in which psy-chological safety matters for learning and fulfillment at work.

Finally, my husband, George Daley, put up with me as I putmore and more time into working and writing. His love and con-fidence sustained me and made it possible for me to devote everyspare moment to getting this done. He was there every step of theway for the past 25 years, never losing faith in me or in my work.While I spend my days studying leaders who make a difference in theworld, George is one – having taken on the challenge of leading amajor organization two years ago. Humble enough to claim my ideashave helped him succeed, George has thus given me even greaterconfidence that they may help others as well. This book is dedicatedto him.

About the AuthorAMY C. EDMONDSON

Nearing graduation from Harvard College over three decades ago,Amy Edmondson took a leap of faith and wrote a letter to apersonal hero, seeking advice about employment. To her surprise,Buckminster Fuller wrote back. His letter arrived barely a week laterwith far more than advice. The legendary inventor, architect, andfuturist offered her a job. Spending the next three years as Fuller’s“chief engineer,” she developed an intense and enduring interestin what leaders and organizations can do to create a better world.Today, as the Novartis professor of leadership and management atthe Harvard Business School, Edmondson studies leaders seekingto make a positive difference in the world through the work theydo in organizations of all kinds. The research described in thisbook captures the central thread that has run through her academiccareer – creating work environments where people can team up anddo their best work.

Edmondson has been on the Harvard faculty since 1996 andteaches courses in leadership, teaming, decision-making and organi-zational learning. Her more than 70 articles have been published inHarvard Business Review and California Management Review, as well asin academic journals such as Administrative Science Quarterly and theAcademy of Management Journal. Before her academic career, she wasdirector of research at Pecos River Learning Centers, where sheworked with CEO Larry Wilson to design and implement changeprograms in large companies. In this role she discovered a passion for

219

220 About the Author

understanding how leaders can build organizations as places wherepeople can innovate, learn, and grow. Edmondson’s prior books –Teaming: How Organizations Learn, Innovate, and Compete in the Knowl-edge Economy (2012), Teaming to Innovate (2013), Building the Future:Big Teaming for Audacious Innovation (2016), and Extreme Teaming(2017) – explore the challenges and opportunities of teamwork indynamic environments. Her first book, A Fuller Explanation: TheSynergetic Geometry of R. Buckminster Fuller (1986), clarifies Fuller’smathematical contributions for a nontechnical audience.

Edmondson’s contributions to management research have beenrecognized by the 2018 Sumantra Ghoshal Award for Rigor andRelevance in the Study of Management, the 2017 Thinkers50 TalentAward, the 2004 Accenture Award for significant contribution tomanagement practice, and the Academy of Management’s CummingsAward for midcareer achievement in 2006. She has been namedone of the most influential thinkers in management by the biannualThinkers50 list since 2011 (#13 in 2017). HR Magazine has listed heras one of the 20 Most Influential International Thinkers in HumanResources. Edmondson received her PhD in organizational behavior,her AM in psychology, and her AB in engineering and design fromHarvard University. She lives in Cambridge, Massachusetts, with herhusband, George Daley, and their two sons.

Index

Abilities, confidence, 168“Accident,” term (usage), 155Advanced Management Program

(Harvard Business School),168

Agile execution, 187Alphabet, 117Android (Google)

operating system, 65platform, 189

Anglo American, work, 165“Anything goes” environment,

17–18Apathy zone, 18–19Appreciation, expression, 173–174Argument, winning (avoidance),

111–112ATC clearance, 81Aurelius, Marcus, 129Authority, confidence (excess),

83–86Avoidable future, avoidance, 53,

68–70

Bad, embracing, 105–107Baer, Markus, 40Bank personnel, sales goals, 62Barry-Wehmiller, 135

approach, 123“Guiding Principles of

Leadership,” 121

psychological safety, 120union support, 120values/methods systematization,

121Barry-Wehmiller University,

founding, 121“Be a Don’t Knower” (Fisher), 168Beim, David, 66–67

nonconfrontational/deferentialstyle, 67–68

Belongingbuilding, 201–202psychological safety, relationship,

201–202Bennis, Warren, 12Bezos, Jeff, 96Bischoff, Klaus, 56Blackberry, RIM introduction, 64Black Lives Matter, 96Blameless reporting, 157Blameworthy,

consideration/treatment,176–177

Boeing 747s, collision, 79–82Boisjoly, Rogert, 192Borderline personalities, impact, 207Boss

role, framing, 164twork psychological safety,

199–200“Bottom-up” changes, 193–194Bradley, Bret, 44

221

222 Index

Brainstorming, usage, 191Braintrust, 105–109, 112, 118,

190Bridgewater Associates, 123, 167

employees, attrition rates,111–112

founding, 109–110Bryant, Adam, 171Bryndza, Jessica, 96Business failures, 71, 189

Cable, Dan, 169California Air Resources Board

(CARB), 54Camp, Garrett, 94Candor

creation, 206definition, 105extremeness, 109–13reality, 104–109

“Captain of Moonshots,” 117Care, permission, 115–116Carmeli, Abraham, 169Carroll, Cynthia, 138–142, 165, 170

harm, reduction attempts, 166Cassandra, 86, 90Catmull, Ed, 105–108, 160Cause-effect relationships, 174Centers for Medicare and Medicaid

Services (CMS) pilotprogram, usage, 137–138

Challenger (space shuttle), disaster,86–87

Chaplin, Charlie, 58, 167Chapman, Bob, 120–122, 135Check pilot, ability (testing), 80–81Chernobyl, disaster, 89Children’s Hospital and Clinics, 153,

170failure, productive response,

176–177focused event analysis, 157–158staff, silence, 156

China, psychological safety(creation), 207–208

Clean diesel engine design, inability,62–63

Clean diesel vehicles, 54software code, 55

Cockpit Resource Management(CRM), 131, 134

Cockpit training, change, 82Collaborative process, production,

115Colleagues

receptivity, 38–39true selves, 204–205

Columbia (space shuttle), disaster,78–79, 191

Comfort zone, 18–19Command-and-control hierarchy,

60Command, direct line (benefits), 83Commitment, recommendation,

205–206Communication

challenges, 43misunderstanding, 132requirement, 164

Community Bankingdivision, employees (impact), 63employees, motivation, 61

Companyemail addresses, usage (avoidance),

179success, top-down dictators

(impact), 203–204target goals, 59

Compassion, recommendation,205–206

Compensation, decisions, 110Confidence

absence, overcoming, 39excess, 83–86gaining, 168problems, knowledge (sharing),

38–39Conflict

navigation, 44usage, 43–44

Constructive feedback, 106Consumer Financial Protection

bureau (CFPB), 61

Index 223

Continuous growth, enjoyment,113–114

Continuous improvement, 207Continuous renewal, 187–189Conversations, logic (enforcement),

111–112Costa, Mark, 25–26, 176Counterfactual data, access

(absence), 203Counterproductive workarounds,

38Courage, impact, 82Coworkers, communication

frequency, 39Creative energy, production, 115Crew Resource Management

(CRM), 82, 134Criticism, risk, 114Cronbach’s alpha, 20, 213–214Cross-cultural differences, 207–208Cross-sell, 61Cross-selling strategy, 69

execution, 63Culture, change, 192–193Culture of telling, 170Curiosity

humility, combination, 167–168recommendation, 205–206

Customer accounts, CommunityBanking employee opening,63

Dalio, Ray, 109–113, 123, 145, 167,198

Damore, James, 178Dana-Farber Cancer Institute,

83–85Dangerous silence, 77Data collection/analysis, 30DaVita Academy, 137DaVita Kidney Centers, 46, 135,

166teammates, importance, 137–138Total Renal Care, 136

DaVita University, 135DaVita Village Network, 136Debate, occurrence, 112

Decision makingdeliberative decision making,

189–191improvement, 165–166

conflict, impact, 43–44productive decision making, 44

Deming, W. Edwards, 191“Design Kitchen,” 119Detert, Jim, 31–32Dieselgate, 54

root cause, 57–58Disaster, enabling, 91–92Discipline

impact, 196–197self-discipline, 206

Discretionary work, willingnessindex, 42

Diversitybuilding, 201–202performance, negative

relationship, 45psychological safety, relationship,

201–202stance, 178usage, 44–45

Don’t knower, action, 113–116Dudenhoffer, Ferdinand, 59Dudley, Bill, 66Duhigg, Charles, 40–41Dweck, Carol, 174

Eastman Chemical Company, 25–26Educational backgrounds,

consideration, 41Effectiveness, guarantee (absence),

204–205Effort

harnessing, 188–189motivation, 166–167

Eileen Fisher Leadership Institute,founding, 116

Electronic media, communicationchallenges, 43

Eli Lilly, failure parties, 177Embarrassment, risk, 114Emergency Response Center

(ERC), 143–144

224 Index

Emotional harm, conditions(creation), 77–78

Emotional intelligence, problems,207

Empathybuilding, 179place, 106

Employeescare, 119–123engagement, measures

(validation), 42failure, 45–46motivation, 58perks, absence, 26satisfaction, importance, 41–42survey, 169

Engagementbarriers, overcoming, 188–189creation, 45

Errorsabsence, 35–36admission, 31open discussion, 155–156reporting, appeal, 17

Everybody Matters (Sisodia), 120Excellence, creation, 206Expertise-diverse teams,

performance, 44Extreme candor, 109–113

Failing to fail, 119Failure

archetypes,definitions/implications,163t

avoidance, 53, 59–60culture, 192czar, 161data source, 160destigmatization, 175–177, 176tevaluation, 118–119failing, 119freedom, 108–109impact, 161–162intelligent failure, 117learning to learn, 160–161parties, 177

prevention, 162, 208productive response, 177

productive response, variation,180

psychological pain, 108real failure, defining, 119reframing, 158, 160–162reporting, fear, 160role, 161safety, 117–118, 160success, 116–119types, productive responses, 180ttypology, implications, 175

“Failure,” term (usage), 155Fareed Zakaria GPS, 45FEA. See Focused event analysisFear

absence, 192climate, behaviors (impact), 194culture, insidiousness, 59expulsion, 191impact, 14–15interference, 144interpersonal fear, 165, 172–173,

196motivation, problem, 13–15, 58“No fear” federal workplace,

creation, 192understanding, 138

Fearless organization, creation, 146Fearless workplace, 103Federal Reserve of New York

(FRBNY), 60, 92, 198condemnation/criticism, 66consensus, striving, 67

Feedback, 110, 173. See alsoConstructive feedback

group, people (impact), 106–107provision, 196

Fictional vignettes, design, 32, 34Financial system, collapse, 68Firing, decisions, 110Fisher, Eileen, 113–116, 123,

165–168, 190Flight 1549, 130–131

non-normal situation, 130Focus, creation, 114

Index 225

Focused event analysis (FEA),157–158, 177

Ford, Henry, 57, 204“Foundry,” 119Fowler, Susan, 93–96, 194–195Frei, Frances, 193–194Frese, Michael, 40Frontline staff, stress, 42Fukushima Daiichi Nuclear Power

Plant, 87–92, 142control, 144–145

Fukushima Daini Nuclear PowerPlant, 142–145, 165

damage, assessment, 143

Game-Changer, The (Lafley), 160Gazetta, Frank, 116Geographic dispersion, overcoming,

43Gibbs, Jennifer, 43Gibson, Charlie, 79Gibson, Cristina, 43Glass, Ira, 67–68Goffman, Erving, 4–5, 8“Going for Gr-Eight,” 61–63Goldman Sachs, 67Good, journey, 105–107“Good news” stories, simplicity, 104Googler-to-Googler (g2g) network,

172–173, 195Google team, Project Aristotle,

40–41Google X, 117–118, 123, 160, 165Government bureaucracy,

responsibility, 92“Great East Japanese Earthquake,” 87Great Recession, 120Green Car of the Year (2008), 53Groupe Danone, 173Group-level phenomenon, 12Groupthink, 67“Guiding Principles of Leadership”

(Barry-Wehmiller), 121

Halbesleben, Jonathon, 38Hall, Amy, 115Ham, Linda, 79

Harris, Sydney, 77Harten, Patrick, 131, 133Harvard Business School

Advanced Management Program,168

leadership programs, 191Hatz, Wolfgang, 54Healthcare delivery, explanation, 155Help, seeking (appeal), 17–18“Here-and-Now Humility”

(Schein), 168Hewlin, Patricia, 30Hierarchy

de-emphasis, 114psychological pull, 82

Hirak, Reuven, 169Hobbies, consideration, 41Hooke, Casey, 172Hornsey, Liane, 194Hospital care, error-prone system,

155Huang, Chi-Cheng, 40Hudson Miracle, value, 134Human health/safety, fostering, 134Human interactions, importance,

133Humble listening, 114–115Humiliation, risk, 114Humility

confidence, contrast, 168curiosity, combination, 167–168

Humor, absence, 193–195

Ideas, withholding, 31Impostor syndrome, 161Incentives, decisions, 110Inclusion

building, 201–202psychological safety, relationship,

201–202Industries, learning, 133–134Innovation

culture, 192fostering, 43–44impact, 66psychological safety, relationship,

40

226 Index

Inputrequests, 122–123structures, design, 172–173

Inquiry, 170proactive inquiry, 167, 170–172skills, development, 179

Institut Européen d’Administrationdes Affaires (INSEAD), 190

Intelligent failure, 117Interdependence

appreciation, 177emphasis, 162, 164levels, attention, 166

Interdependent departments,priorities (conflict), 154

Interpersonal fear, 172–173, 204problem, 196sensibility, 165

Interpersonal riskmicro-assessments, 134overcoming, 166–167perspective, 164

Inter-term reliability, 20Interview data, coding, 20–21Inviting Participation, 123, 154, 156iOS (Apple), 189iPhone, impact, 65Ishibashi, Katsuhiko, 88

Madame criticism, 88–89

JapanActive Fault and Earthquake

Research Center, 90national energy security, goal, 92nuclear meltdown, 87–91psychological safety, creation,

207–208Jiang, Pin-Chen, 40Jobs, Steve, 204Jogan tsunami, 90–91“Just kidding” moments,

193–194

Kahn, William, 12Kalanick, Travis, 94

Uber exit, 95–96Khosrowshahi, Dara, 96, 193–194Knowledge

marketplace, 173sharing, 38–39workers, 58

Kurokawa, Kiyoshi, 91Kyoto Protocol, 89

Lafley, A.G., 160Lasseter, John (harassment), 107Leaders

job, 200participation, invitation, 156–157productive responses, 157–158stage, setting, 155–156success, learning, 207tool kit, 154–158, 176–177

usage, 159tVUCA interaction, 166

Leadership, 146effectiveness, 56–57self-assessment, 181–182

“Lean Forward, Fail Smart Award,”192

Learn-how, 36–37behaviors, 37

Learninganxiety, 12behavior, 35

psychological safety,relationship, 39–40

creation, 206increase, 169inhibition, fear (impact), 14–15mindset, 167–168natural part, 108opportunity, 205orientation, power, 174support, work environment

(impact), 35–39zone, virtual team (impact),

131–132Learning to learn, 160–161Learn-what, 36–37

Index 227

Lehman, Betsy, 83–85chemotherapy, 83–84

Lehman, Mildred K., 85Lekgotla, 140Leningrad, flood (1924), 14Leroy, Hannes, 35–36Listening, 114–115

impact, 199importance, 96

Los Rodeos Airport, 80Lutz, Bob, 56–57

Madame, Haruki, 88Mahfouz, Naguib, 153Management risk, 21Manager change (absence), people

(interaction advice), 205–206Marcus, Roy, 137–138Mask, removal, 200Masuda, Naohiro, 142–146, 165Maxwell, John, 187Meaning, environment (creation),

121Meaningful work/relationships,

value,109

Medical errors, 85Medical team, efforts, 136–137Meetings, silence (usage), 114Mental health, 42Merchant, Nilofer, 5Meritocracy, 95#MeToo movement, 92–96, 107,

194–195Meurs, Klaas, 80–82Milano, Alyssa, 92–93Milliken, Frances, 30Mindfulness, creation, 114Mines, safety protocols (usage), 141Mining

harm, reduction, 166–167shutdown, 139–141

Minorities, engagement (creation),45

Mistakephobia, 111Mistakes, learning, 35–36Modern Times (Chaplin), 58

Moody-Stuart, Mark, 139Morath, Julie, 153–157, 165, 170

terminology, introduction, 155Morrison, Elizabeth, 30Morton-Thiokol, 86–87“Motivator Report,” 62MTV, programming work, 172Mulcahy, Anne, 168

Narcissism, impact, 207NASA

leaders, emphasis, 166space shuttle disasters, 78–79,

86–87, 191National Union of Mineworkers,

141National Women’s Law Center, 195Ndlovu, Judy, 140Near-perfection, desire, 158Nembhard, Ingrid, 36, 169Neonatal Intensive Care Unit

(NICU), 169, 173babies, delivery, 3nurse, speaking up, 154protocol, 7quality improvement project

teams, 36–37Nitrous oxide (NOx), production,

54–55“No fear” federal workplace,

creation, 192Nokia, 60, 63

avoidable failure, 64comeback, 190emotional climate, 64external market threats, 65operating system, 189R&D culture, 65rise/fall, 64success, 65–66

Non-governmental organizations(NGOs), 195

Not-knowing (Fisher), 190Nuclear Accident Independent

Investigation Commission(NAIIC), 91

228 Index

Nuclear Industrial Safety Agency(NISA), policing hesitation,89, 90

Nurses, study, 35–36

Off-site company sustainabilityconference, usage, 115

Oil shocks (1970s), 89Okamura, Yukinobi, 90Ombudspersons, confidentiality,

203“One for All and All for One”

motto, 135–138, 166One-on-one mentoring, 172Open-minded disagreements,

111–112OpenTable, 160Operational performance,

improvement, 173Organization

fearlessness, 201strategy, framing, 70

Organizational learningprocess, 179requirements, 71

Osterloh, Bernd, 59

Paper trail, 25Participation, invitation,

156–157process, 167–173

Patient Safety Steering Committee(PSSC), initiative, 157

Patton, George, 142People

responses, 167–173treatment, 121

People Experience, 96Perfectionism, discussions, 161Performance

measurement, 40problem, 70psychological safety importance,

reasons, 39–41sacrifice, 55unit performance, improvement,

169

Performance standardslowering, psychological safety

(contrast), 17–19psychological safety, comparison,

18fPersonalities, self-assurance, 112Personality

factor, psychologically safety(contrast), 16

traits, consideration, 41types/skills/backgrounds, mix, 41

Personal values/goals, 205Physical harm, conditions (creation),

77–78Piech, Ferdinand, 56–57Pittman, Bob, 171–172Pixar Animation Studios, 14, 46,

105–109, 118, 123, 160Braintrust, 105–109, 112, 118,

190Power distance, 207

cultural differences, 208“Powerful questions” attribution,

identification, 170–171Power, impact, 169Power plants, construction allowance

(government records), 88Predictive validity, 20Presentation of the Self in Everyday

Life, The (Goffman), 4Price, Christina, 3–4, 6–8, 17Pride, environment (creation), 121Principles (Dalio), 109, 111, 145Proactive inquiry, 167, 170–172Process improvements, 122Process-laden work, 121–122Process, outcome (relationship), 175fProductive conflict, 111–113Productive decision making, 44Productive responses, 180t

process, 173–180variation, 180

Project Aristotle, 12, 40–41aftermath, 45

Project Foghorn, 116Promotions, decisions, 110Promotions/protections, 94–96

Index 229

Psychologically safe employees,engagement, 41–42

Psychologically safe organizations,creation, 208

Psychologically safe workenvironments, 165

impact, 134–135learning, 123–124

Psychologically safe workplace, 6–8advocacy, 198–199creation, 138, 146profile, 104time, usage, 197–198

Psychological safety, 8–12absence, 130, 203assistance, 43building, 195, 208–209

leader tool kit, usage, 159tcertainty, 26–29confusion, 197creation, 140, 146, 199, 209cultivation, 165defining, 15–19demonstration, 134diversity/inclusion/belonging,

relationship, 201–202dynamism, 189effects, 28–29efficiency source, 197emphasis, 43–45establishment/enhancement, 169excess, 195–197failure, destigmatization, 176tFAQs, 195–208group building, 36groups, 29–30impact, 156importance, 12–13

reasons, 39–41improvement, 21–22innovation, relationship, 40insufficiency, 69–70leader, success (learning), 207learning behavior, relationship,

39–40measurement, 19–21media mentions, 27–28, 27f

niceness, contrast, 15–16norms, inclusion, 190organizational commitment,

relationship, 42panacea, 196–197performance standards

comparison, 18flowering, contrast, 17–19

personality factor, contrast, 16power, 119–120practice, research (usage), 45–46predictions, 37presence/absence, detection,

20–21research, 29–30restoration, 195rewards, 120robustness, survey measures

(variations), 213–215role, emphasis, 43, 195stage, setting (process), 158–167studies, 44survey measure, 20fteam psychological safety,

citations, 28ftrust, comparison, 16–17whistle-blowing, relationship,

202–203work, framing, 160–166

Psychological/societal forces,asymmetry, 188

Public self-expression, ambiguity,180

Qatar, sovereign wealth fund, 59Qualitative case-study research,

20–21Quality environment, 36–37Quality improvement (QI) project

teams, 36–37“Quality of Sale” Report Card

(Wells Fargo), 62–63Quarles, Christa, 160Questions

power, attributes, 171“powerful questions” attribution,

identification, 170–171

230 Index

Questions (continued)reason, 85revelation, 208

Radical truth/transparency, 109“Rapid Evaluation,” 118–119Ratatouille (film), 14Rathert, Cheryl, 38Real failure, defining, 119Regulators, regulation, 66–68Regulatory capture, 67–68Reporting policy, blame (absence),

158Report of Systemic Risk and Bank

Supervision (2009), 66–67Research, usage, 45–46Respect, conveyance, 199Return on assets, longitudinal

change, 40Ride-sharing economy, 94RIM, 64Risk, mitigation, 168Risk, taking, 116, 174Rocha, Rodney, 78–79Rogers, Ed, 191–192Role model, 25Roosevelt, Franklin D., 103Rozovsky, Julia, 3, 41

Safety Summit, 141Safe zone, creation, 199Sales numbers, hitting, 62Sallan, Stephen, 83Schein, Edgar, 12, 168Schmidt, Oliver, 53Schreuder, Willem, 80–82Scolese, Christopher, 192Segarra, Carmen, 68Self-assessment questions, 181Self-confidence, 168Self-discipline, 206Selfish agenda, absence, 106Self-protection, 188

perception, 167Self-report, 40Senior executives, engagement, 71Sexual attention, suffering, 92–93

Sexual harassment, experiences, 93Siemsen, Enno, 39Silence

culture, 86–92impact, 30–35, 92–96importance, 79–82, 156reasons, 31rewards, 188selection, 35sounds, hearing, 191–193understanding, 138usage, 114victory, reason, 34twarnings, dismissal, 87–90

“Silence Breakers” (TIMEMagazine), 96

Simmons, Rachel, 161Sisodia, Raj, 120Situational humility, 167–169

demonstration, 168Skiles, Jeffrey, 129–133Smart failures, honoring, 119Smart process design, 197Smith College, 160–161

Wurtele Center for Work andLife, 161

Smith, Diana, 44Social media

platforms, personal opinionsexpression, 179

problem, 95silence, impact, 92–96

Solutions, develop-ment/commercialization(goal), 117

South African Department ofMinerals and Energy, 141

Space shuttleChallenger disaster, 86–87Columbia disaster, 78–79

Speaking upautomatic calculus, 34failure, 78–79psychology, aspect, 79risk, 32

Staff meetings, orchestration,165–166

Index 231

Standards, importance, 54–60Stanton, Andrew, 106–107Strategy, agile approach (adoption),

70–71Stretch goal, stretching, 60–63“Study,” term (usage), 155Stumpf, John, 61Success

innovation, impact, 66requirements, 71

Sullenberger III, Chesley, 129–133Superstorm Sandy, 162Symbian, 189

operating system, 63System complexity

appreciation, 177problem, 154

Tacking, 209Taken-for-granted rules, 33t, 34Talent, unleashing, 146Task-based conversations, 111Team psychological safety

citations, 28fconcept/measure, 28

Teamsdiagnostic survey, 9error rates, 9–10member performance, rating, 40

Teamwork, importance, 161Teller, Astro, 117–119, 160Telling, culture, 170Tertiary care hospitals

complexity, 154operations, error-prone nature

(re-explanation), 156Thiry, Kent, 135–136, 166Threat and error management

(TEM), 134Three Mile Island, accident, 89“Time’s Up” Legal Defense Fund

(National Women’s LawCenter), founding, 195

Time, usage, 133“Toe-stepping,” 194Toe-stepping value, 95

Tokyo Electric Power Company(TEPCO), 144

risk acknowledgment, 89–91Top-down culture,

cheating/coverup(by-products), 70–71

Top-down dictators, impact,203–204

Top-down strategy, 69–70Total quality management (TQM),

38Total Renal Care, 136Toy Story (movie), 104–106Toy Story 2 (movie), 105–106Transparency, 198–199

aggressiveness, 198injunction (Dalio), 194levels, 198norm, violation, 194radical truth/transparency, 109whiteboards, usage, 142–146

Transparency libraries, 110–111Trust

destruction, practices, 121environment, creation, 121increase, 190psychological safety, comparison,

16–17Truth

fear, 63–66radical truth/transparency, 109

Tucker, Anita, 36, 37, 169Turnover intentions, 42

Uber Technologies, Inc., 93–96problems, 193sexual harassment, experiences,

93–95Uncertainty

emphasis, 162, 164levels, attention, 166

Unconscious calculators, 4–6Union support, 120Unit performance, improvement,

169US Airways, Cockpit Resource

Management (CRM), 131

232 Index

Value creation, impact, 70Value (gaining), diversity (usage),

44–45van Zanten, Jacob Veldhuyzen,

80–82Vaughn, Diane, 191Verdin, Paul, 70Vigilance, importance, 161Violations, sanctioning, 178–180Virtual teams, 43Virtual zone, usage, 131–132Voice

barriers, overcoming, 188–189implicit theories, 32, 34–35mission criticality, 39productive responses, process,

173–180requirement, clarification,

162–166rewards, 188threshold, 197

Voice at work, taken-for-grantedrules, 33t

Voice-silenceasymmetry, 34calculation, silence (victory), 34t

Volatility, uncertainty, complexity,and ambiguity (VUCA), 19,26–27, 60, 70, 166

conditions, 174success, requirements, 71value creation, impact, 70

Volkswagen, 174command-and-control hierarchy,

60compliance, 55coverup, denial, 55diesel engines, problem, 58–59,

107emissions scandal, effects,

59–60engineers, blame, 56failure, avoidance, 53standards, importance, 54–60stretch goal, stretching, 60–63terror, reign, 57truth, fear, 63–66

Volkswagen Group, 53Vulnerability, expression, 200Vuori, Timo, 190

Warnings, dismissal, 87–90Wells Fargo, 60, 174

cross-selling strategy, 69“Quality of Sale” Report Card,

62–63success, 60–61

West Virginia University, Center forAlternative Fuels, Engines,and Emissions, 55

Whistle-blowing, psychologicalsafety (relationship),202–203

Whiteboards, usage, 142–146Why Worry? (Ishibashi), 88Winterkorn, Martin, 54, 164

company rules, strictness,59–60

leadership, impact, 56–57soft spots, 58villian, role, 56

Words, usage, 130–134Work

colleagues, true selves, 204–205emotional commitment, 41–42engagement, 42error-prone nature, 156framing, 160–166interdependent work,

communication(requirement), 164

process-laden work, 121–122psychological safety, 199–200quality, erosion, 180self, supply (problems), 205

Workaroundsoccurrence, 38problems, 37reduction, 37–38

Work environmentimpact, 35–39knowledge, sharing, 38–39mistakes, learning, 35–36quality environment, 36–37

Index 233

Workersfatalities, avoidance, 158safety, speaking up, 138–142

Workforce, diversity, 201Workplace

fearless workplace, 103nurturing, 187phrases, usage, 200psychologically safe workplace,

6–8

psychological safetyabsence, 29manifestion, 104

psychological safety climate,permeation, 68

silence, importance, 79–82Wrong-doing, speaking out,

28

X (project). See Google X

WILEY END USER LICENSE AGREEMENTGo to www.wiley.com/go/eula to access Wiley’s ebook EULA.

www.wiley.com/go/eula

The Fearless Organization - Chools

Documents

Transcript of The Fearless Organization - Chools